A coroner’s report last week (April 25) revealed that a man “unintentionally overdosed” on benzodiazepines that he bought from “illicit” online providers posing as “regulated” pharmacies.
Assistant coroner for Ceredigion, Wales, Louisa Corcoran said that Christopher Brazil, 45, had “suffered from an accident some time before his death in which he sustained injuries that left him with pain” and was “prescribed some medication” from his GP.
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“In a bid to self-medicate...to manage his pain and at times, poor mental health, Brazil also sourced additional medicines and drugs...from illegal websites that depicted themselves as safe, regulated online pharmacies,” she added.
Brazil was “struggling with physical pain and mental health issues” – which also included sciatica and depression - and was “susceptible to using this unlawful method, which was quick and readily available”, Corcoran said.
He died after “inadvertently overdosing on benzodiazepines...[that] were not prescribed by his doctor or the NHS”, the report said, adding that investigations by the police and the medicines watchdog revealed that he bought the drugs from “unlawful providers”.
“Next day” delivery
The drugs in Brazil’s last order “were delivered the next day via Royal Mail”, the report said.
He was able to buy “prescription drugs from illicit providers on a regular basis,” Corcoran found, noting that A&E records from two separate occasions – in February and April 2022 – showed he was “intoxicated on benzodiazepines”.
This happened “before he subsequently died from benzodiazepine toxicity in August 2022”, she said.
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According to the coroner’s report, evidence showed that Brazil was “not suicidal” but was “anxious to manage pain and was not directed by a healthcare professional as to how much to take and when”.
Corcoran said that this case raises concerns that “there are unregulated and unlawful websites offering prescription-only medicines (POMs) and controlled drugs, which look legitimate and are found easily from simple online searches”.
These websites mean “vulnerable and susceptible people are exposed to counterfeit or unsafe medications”, she said, adding that “there is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs”.
“Unlawful and unethical”
Her report also highlighted that there are “insufficient or no measures” on these websites “to verify patient medical history before selling the medication and drugs”.
“There is a lack of guidance regarding dosage [and] a lack of safeguards to prevent incorrect self-diagnoses or misuse,” she added.
Read more: Coroner: Patient overdosed after pharmacy ‘welfare concern’ missed
Corcoran raised concerns “that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours”, noting that this means “these illegal websites may be more appealing to some than lawful sources”.
She sent the report to the Department of Health and Social Care (DH), the Department for Digital, Culture, Media and Sport (DCMS), Brazil’s GP, the Medicines and Healthcare products Regulatory Agency (MHRA) and the police, who all have until June 18 to respond.
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An MHRA spokesperson told C+D that they were “saddened to hear of the case” and offered “sincere condolences” to Brazil’s family.
“Patient safety is our top priority [and] we take all prevention of future deaths reports very seriously and will review the findings carefully before providing a response within 56 days,” they added.
C+D also approached the DH, while the DCMS declined to comment.
If you have been affected by any of the issues in this article, you can also contact Pharmacist Support by emailing info@pharmacistsupport.org or calling 0808 168 2233/0808 168 5133 for free
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