A coroner has raised serious concerns regarding inadequate safety checks by medicines wholesalers following the death of Paul Pidgeon, who fatally overdosed on painkillers bought without proper verification of his status. Mr. Pidgeon, a mechanic from Surrey who owned a garage in Wimbledon, held a business account with Booker, a wholesale distributor owned by Tesco. In February 2022, he made a bulk purchase of over-the-counter paracetamol and ibuprofen, and less than a month later, used his trade account to buy more paracetamol from the same Booker branch.

Coroner Anna Crawford concluded that Mr. Pidgeon's business did not involve the onward supply of medication to the public, and it appeared no checks were carried out by Booker to confirm his authorization prior to these sales. Tragically, Mr. Pidgeon was found dead in March 2022, having deliberately overdosed on paracetamol, with empty packs of both paracetamol and ibuprofen beside him. Investigations determined his death was caused by 'paracetamol toxicity', though his intentions could not be definitively established.

In a 'Prevention of Future Death' report, Ms. Crawford highlighted that Booker in Wimbledon, and potentially Booker more broadly, may be selling medicinal products to customers not authorized or entitled to supply them to the public. She expressed concern that this poses a risk of future deaths, especially given the potential for significant amounts of medicines to be sold in single transactions. Health leaders have long warned against obtaining medicines from unregulated sources, including online 'pharmacies', yet a lack of regulation persists, allowing potentially fatal drugs to remain accessible.

Legitimate online pharmacies, as mandated by the General Pharmaceutical Council (GPhC), must display the GPhC logo and registration number for verification. Ms. Crawford's report also noted that Mr. Pidgeon had pre-existing coronary artery disease and hepatic steatosis (fatty liver disease), both of which made him more susceptible to paracetamol toxicity by increasing blood pressure and raising the production of a toxic metabolite, NAPQI.

The coroner emphasized that wholesale suppliers must ensure they supply medicinal products only to those possessing a wholesale distribution authorization or those legitimately authorized to supply medicines to the public. Wholesalers are urged to comply with these guidelines by diligently requesting and checking a customer's status. Copies of her report were sent to Mr. Pidgeon's family, the UK medicines watchdog (MHRA), and the chief coroner, all of whom, Ms. Crawford warned, 'have the power' to prevent future deaths.

In a seven-page response, Booker extended its 'sincere condolences' to Mr. Pidgeon's loved ones, stating it was unaware of the 'tragic circumstances' and regretting not being invited to make representations at the inquest. Booker noted that Mr. Pidgeon had held an account for over 20 years, meaning the qualification system for members would have differed when he joined. Consequently, Booker is no longer able to access the original documents proving his business ownership or its nature, speculating there might have been a 'miscommunication' during onboarding.

Booker further stated that its systems have significantly changed since 2022 and now include a stringent qualification process requiring customers to prove their entitlement to supply to the public. The wholesaler expressed confidence that its current systems would prevent unauthorized sales of medicines. For anyone needing help or support, the Samaritans can be contacted anonymously in the UK on 116 123, or in the US, the national suicide and crisis lifeline is available by calling or texting 988.