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A health board’s failure to update guidelines for using oral methotrexate to treat rheumatological conditions since Pharmacy First was launched has led to “ambiguity” over which professionals patients should seek advice from, a coroner has found.

In a February 20 report to prevent future deaths, assistant coroner for Cheshire Elizabeth Wheeler examined the circumstances that led to Alan Crabtree’s death from methotrexate-induced pancytopenia at the age of 84 on March 1 last year.

Mr Crabtree died 11 days after being admitted to Macclesfield Hospital with “idiosyncratic” side effects from the drug, which he was prescribed to treat “ongoing rheumatoid issues”.

Ms Wheeler found that the Share Care Protocol developed by Greater Manchester Medicines Management Group (GMMMG) in 2017 and still in use today “does not reflect current practice” around recommended starting doses for and titration of methotrexate in rheumatological patients. The protocol was due to be renewed in October 2020.

The assistant coroner also noted that Mr Crabtree’s family had initially brought him to a local community pharmacy to seek advice for his symptoms of sore throat, mouth ulcers and difficulty swallowing.

Ms Wheeler found that the 2017 guidelines state methotrexate patients should “seek medical attention” if they develop symptoms of a blood disorder, which she described as “ambiguous” and not in line with Arthritis UK’s recommendation that patients should inform “their doctor or nurse specialist” if they experience symptoms like sore throat and mouth sores.

She wrote: “Since [2017], the Pharmacy First scheme has come into effect. 

“The guidance therefore does not reflect the changes in the relevant responsibilities between secondary care, GPs and community pharmacists leading to ambiguity as to what type of healthcare professional a patient should consult and potentially fatal delay in ceasing methotrexate or commencing treatment for toxicity for the same.”

GMMMG is required to respond to the coroner’s report by April 17.

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