‘Limitless’ online drug availability puts lives ‘at risk’, coroner warns after death

Regulatory “gaps” left a patient unprotected from companies selling “huge” quantities of “powerful drugs” online, coroner Isabel Thistlewaite has said.

In a letter sent to the Department of Health and Social Care (DH) last month (June 4), she said that drugs purchased from one online company “contributed to [the] death” of 64-year-old Nigel Dixon.

The “elite” army veteran, who had a history of “physical and mental health issues” including depression, suicide attempts, chronic alcohol misuse and opioid dependence, was found dead in his home on February 13 2023 due to “Morphine and Zopiclone toxicity”, the letter said.

The coroner added that while Dixon was not being prescribed sleeping pill Zopiclone at the time, he was “honest with his GP about the fact he purchased drugs online to supplement his prescriptions”.

“Gravely concerning”

Thistlewaite added that Dixons’ family provided “documentary evidence of him purchasing drugs online before he died”, while a GP giving evidence at the inquest deemed the amount he was able to purchase “huge”.

The GP also “raised concerns about the safety and quality control of the drugs being supplied,” the letter said.

“It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to,” the coroner added.

“There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk,” she said.

She added that the sale of a “larger dose” of tablets “in a much larger quantity than would ordinarily be prescribed online risks an accidental or intentional overdose of the drug and also risks the drug being sold on the black market”.

Thistlewaite said that the company – which was not named - did not communicate with Dixon’s GP and she could not see how it could “check whether customers are placing duplicate orders with other websites”.

“There seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all,” she added.

She stressed that Dixon was offered “no protection…by the online company who sold him these, and other drugs”.

Pharmacy communication failures

The coroner also found that changes to prescriptions were not communicated properly to the patient’s community pharmacy.

Dixon was “in the process of being weaned off morphine with the support of his GP when he was admitted to hospital on February 3 2023 for an opiate overdose”, the letter said.

He underwent an “abrupt cessation of his morphine use” while at the hospital but when discharged four days later, his discharge letter was “not actioned” leaving him “able to access one weeks’ worth of morphine” through a prescription post-dated prior to his hospital stay, it added.

The coroner said that changes to how software PharmOutcomes is now used at the University Hospitals of Leicester NHS Trust will ensure “that the hospital pharmacist communicates the cessation of drugs like morphine to community pharmacies” in the future.

Calls for tighter regulation

Last week (July 5), Northern Ireland health minister Mike Nesbitt revealed that the country has successfully prosecuted one person, with four more “pending”, over the unlawful supply of counterfeit or unlicensed weight loss drugs.

And last month, C+D exclusively revealed that a “young girl” had to be treated in A&E after presenting with life threatening symptoms after taking weight loss drug Wegovy obtained through Boots Online Doctor.

At the time, the body representing acute doctors raised the alarm with the medicines watchdog about the regulation of “life threatening” weight loss drugs obtained online.

And health secretary Wes Streeting said that a Labour government would look “very carefully” at changing weight loss drug regulation.

In June, C+D reported that analysis by academics at the University of Bath and Lund University in Sweden had revealed a “failing system of drug company self-regulation”, with weight loss drugs consistently being advertised irresponsibly with “serious consequences”.

When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.

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