Coroner Anna Crawford has raised concerns about a Tesco-owned wholesaler that “may be selling medicinal products” to customers who “are not authorised or entitled to supply them to the public”.
In a prevention of future deaths report published last week (October 31), the assistant coroner for Surrey said that this has the potential to “result in significant amounts of medicines being sold in single transactions” and “gives rise to the risk of future deaths”.
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This follows the death by overdose of Paul Pidgeon, who “bulk” purchased paracetamol and ibuprofen – both over-the-counter (OTC) medicines – from wholesaler Booker in Wimbledon on “two occasions”.
Pidgeon, who was a mechanic and owned a garage in Wimbledon, had a “business account” with Booker and used this to purchase the painkillers from the wholesaler’s southwest London store in February 2022, the report said.
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Less than a month later, he used his trade account again to purchase more paracetamol from the same Booker branch, it added.
His business, however, “did not involve the onward supply of medication to the public” and it “[did] not appear that any checks were carried out” by Booker in Wimbledon “to confirm his status prior to the sales” of the medicines, the inquest highlighted.
Booker this week (November 3) offered its condolences to Pidgeon’s family and friends and pointed to its response to the coroner’s report, which stressed that it is “confident” its updated systems would prevent a similar incident from occurring. Read its response in full below.
“Deliberately overdosed”
Pidgeon was “found deceased” with “empty packs” of paracetamol and ibuprofen beside him in March 2022, having “deliberately overdosed on paracetamol”, the report said.
It found that his death was caused by “paracetamol toxicity” but noted that it had “not been possible to establish his intentions”.
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The coroner stressed that wholesale suppliers must ensure they supply medicinal products “only to those who are themselves in possession of a wholesale distribution authorisation or who are authorised or entitled to supply medicinal products to the public”.
She added that wholesalers can “comply” with these guidelines by “requesting and checking a customer’s status”.
And Crawford reiterated concerns that Booker in Wimbledon - “and therefore potentially Booker more widely” - may be selling medicinal products to customers who are not authorised or entitled to supply them to the public.
“Tragic circumstances”
In a seven-page response to the report, Booker told the coroner that it was not aware of the “tragic circumstances of Pidgeon’s death”, nor was it aware “that the inquest was taking place”.
The wholesaler offered its “sincere condolences” to his friends and family but noted that it was “unfortunate that Booker was not invited to make representations at the inquest”.
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At the time of his death, Pidgeon had held an account with Booker “for over 20 years”, it said, explaining that “the qualification system for members would have been different” when he joined.
Given the time that has passed since then, “Booker is no longer able to access the documents that he provided at the time to demonstrate he was a business owner or the nature of his business”, it told the coroner.
It added that “it is possible” there was a “miscommunication regarding the type of business [Pidgeon] owned during the onboarding process...or over the passage of time” but noted that this is purely “speculative”.
“Tighter qualification process”
While the wholesaler “cannot fully explain specifically” how Pidgeon was able to purchase the medicines, “the ultimate root cause was insufficient customer qualification”, Booker said, adding that this has been remedied “with a tighter qualification process”.
It stressed that “various aspects” of Booker systems have changed since 2022 and “matierially [differ]” from those in use at the time of Pidgeon’s death.
Read more: Pharmacy systems under scrutiny after drug interaction ‘sudden death’
“Booker is confident that its current systems would prevent the sale of medicines to any customers who are not authorised or entitled to supply medicines to the public themselves,” it added.
Also commenting on the coroner’s report, the Medicines and Healthcare products Regulatory Agency (MHRA) yesterday (November 5) told C+D that it takes prevention of future death reports “extremely seriously” and that it will “respond in due course”.
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