Playgrounds should be places of freedom, fun and learning. For children, they’re where adventures begin and confidence grows. However, every year, over 40,000 children in the UK are injured while using playground equipment, and many of those injuries are avoidable.

Charlie had tried repeatedly to access his regular prescription over a two-day period. Despite contacting NHS 111, his local health centre and several pharmacies in London, he was unable to get an emergency supply. What Charlie, and those supporting him didn’t know at the time was that he had a legal right to request an emergency supply of repeat medication from any pharmacy, without needing to speak to a doctor.

Representing Charlie’s family at inquest

Charlie’s family instructed Clare Gooch , associate solicitor and David Thomas , director in Switalskis Clinical Negligence department to represent them at the inquest into his death.

The inquest heard that although the right to emergency medication supply exists under NHS guidance and the law, this wasn’t communicated clearly, either to patients or to frontline healthcare staff. The coroner concluded that there were missed opportunities to prevent Charlie’s death and issued a Prevention of Future Deaths report to NHS England.

The report urged NHS England to take urgent steps to ensure that others with time-critical medical conditions are able to access the medication they need, when they need it.

Creating change: the “Charlie Card”

In response to Charlie’s death, his family has stepped into action. Charlies mother, Henrietta has worked alongside epilepsy charity SUDEP Action and the Independent Pharmacies Association to launch the “Charlie Card” - a free awareness tool designed to:

• Remind pharmacists of their legal duty to dispense emergency supplies of repeat medication in a crisis
• Inform people with epilepsy and other long-term conditions of their rights
• Help prevent further avoidable deaths from missed medication

The family launched the Charlie Card publicly in July 2025 outside the Department of Health, and are now calling for improved awareness and training across NHS services and community pharmacies.

You can order or download the Charlie Card for free, click here more information .

Supporting families through inquests

Inquests can be emotionally difficult and legally complex – especially when the circumstances of a death raise serious questions about systems, processes or care.

At Switalskis, we work closely with families to help them understand the inquest process, ensure their voices are heard, and support them in seeking accountability and change. We are proud to have represented Charlie’s family and to support their efforts to prevent similar tragedies in the future.

Call 0800 18 0458 email help@switalskis.com or contact us through the website.