Coroner's Alarm Over Wholesale Medicine Sales
A coroner has issued a serious warning about inadequate safety checks conducted by medicine wholesalers following the tragic death of a Surrey man who purchased painkillers without any verification. Paul Pidgeon, a mechanic who owned a garage in Wimbledon, held a business account with Booker, a wholesale distributor owned by Tesco.
In February 2022, Mr Pidgeon bulk purchased both paracetamol and ibuprofen through his trade account. Less than a month later, he returned to the same Booker branch to buy more paracetamol. Coroner Anna Crawford concluded that his business 'did not involve the onward supply of medication to the public' and that it '[did] not appear that any checks were carried out' by Booker to verify his status before completing the sales.
Tragic Discovery and Investigation Findings
Mr Pidgeon was discovered dead in March 2022 with empty packs of paracetamol and ibuprofen beside him. The coroner determined he had 'deliberately overdosed on paracetamol', with his death caused by 'paracetamol toxicity'. Although investigators couldn't establish his intentions, the coroner noted Mr Pidgeon had two pre-existing conditions—coronary artery disease and hepatic steatosis (fatty liver disease)—that made him 'more susceptible' to paracetamol toxicity.
In her Prevention of Future Deaths report, Ms Crawford expressed concern that 'Booker in Wimbledon, and therefore potentially Booker more widely, may be selling medicinal products to customers who are not authorised' to supply them to the public. She highlighted the risk of 'significant amounts of medicines being sold in single transactions' creating future dangers.
Regulatory Response and Safety Recommendations
The coroner emphasised that wholesale suppliers must ensure they supply medicinal products 'only to those who are themselves in possession of a wholesale distribution authorisation' or to those 'authorised or entitled to supply medicinal products to the public'. She stated wholesalers should comply by 'requesting and checking a customer's status'.
Health leaders have repeatedly warned about patients obtaining medicines directly from wholesalers or unregulated online sources. The General Pharmaceutical Council (GPhC) confirms that legitimate online pharmacies must display the GPhC logo and registration number, which can be verified through their online register.
In a seven-page response, Booker offered 'sincere condolences' to Mr Pidgeon's family and stated it now has 'a stringent qualification process in place for customers' requiring proof of entitlement to supply to the public. The company noted that various aspects of its systems have changed since 2022 and expressed confidence that 'its current systems would prevent the sale of medicines' to unauthorised customers.
The report has been sent to the Medicines and Healthcare Products Regulatory Agency (MHRA) and the chief coroner, with Ms Crawford warning all organisations involved 'have the power' to 'prevent future deaths'.
