Whilst it is understood that Louis had stopped taking his medication due to a perceived increase in suicidal ideation, and no medication was found in his system following his death, the evidence identified that he was being prescribed ADHD medication by both his NHS GP and the private ADHD clinic. Neither organisation was aware of the other’s ongoing prescribing until the time of the inquest. After Louis’ ADHD treatment was transferred to his GP, the plan was for the surgery to continue issuing his medication. Accordingly, on 6 November 2023, the surgery issued a prescription for Lisdexamfetamine ([REDACTED]). However, Louis had attended an appointment at the ADHD clinic the previous day, on 5 November 2023, and the clinic’s notes record that he was to continue on Dexamfetamine ([REDACTED]). Although the medications have similar names, they are distinct drugs with different dosing requirements. Effective management and titration are understood to be essential to ensure therapeutic benefit and limit adverse effects. The concern that has arisen relates to continuity of care between private providers and the NHS once a patient has been diagnosed with ADHD, commenced on medication, and subsequently transferred to GP care. In Louis’ case, communication between the private sector and the NHS was insufficiently clear, and the situation became more complex when he continued to be seen by both the ADHD clinic and his GP. This created opportunities for key information to be missed. Although medication was not directly implicated in Louis’ death, there remains a risk that a patient may inadvertently obtain duplicate prescriptions or become confused about which medication to take. Such scenarios may pose a risk of future deaths. As increasing numbers of patients are receiving ADHD diagnoses and commencing treatment in the private sector due to long NHS waiting times, I am concerned about the robustness of current processes to ensure safe and continuous care following transfer to a GP.