A coroner has raised concerns about insufficient safety checks conducted by pharmaceutical wholesalers after a man died from an overdose of painkillers that he obtained without undergoing any verification process.

The victim, Paul Pidgeon from Surrey, was a mechanic who ran a garage in Wimbledon. He held a business account with Booker, a wholesale distributor owned by Tesco.

In February 2022, Pidgeon made a bulk purchase of paracetamol and ibuprofen—both available over the counter—from the wholesaler.

Just a few weeks later, he used the same trade account to acquire additional paracetamol from the same Booker location.

However, the nature of his business did not involve distributing medication to the public. Coroner Anna Crawford noted that it appeared Booker did not conduct any checks to verify Pidgeon’s eligibility to purchase such quantities of medication.

In March 2022, Pidgeon was found dead, surrounded by empty packets of paracetamol and ibuprofen, having intentionally overdosed on paracetamol.

Investigations found that his death was caused by ‘paracetamol toxicity’ but it had ‘not been possible to establish his intentions’.

In a Prevention of Future Death report, Ms Crawford wrote: ‘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. 

Paul Pidgeon, from Surrey, was a mechanic who owned a garage in Wimbledon and had a ‘business account’ with Booker, a Tesco-owned wholesale distributor

‘Given, the potential for this to result in significant amounts of medicines being sold in single transactions, the Coroner is concerned that this gives rise to the risk of future deaths.’

Health leaders have long issued warnings over patients obtaining medicines directly from wholesalers or other unregulated sources like spurious online ‘pharmacies’. 

Yet despite a number of recommendations designed to clampdown on the supply of prescription and unlicenced drugs over the internet, a lack of regulation means the potentially fatal drugs are still available.

Pharmacy regulator, the General Pharmaceutical Council (GPhC), states that legitimate online pharmacies, where medication can be legally obtained, must display the GPhC logo alongside their registration number — this can often be found on the homepage or ‘about us’ section. 

People can also check if the pharmacy is legitimate by typing the registration number into GPhC’s pharmacy register on its website. 

In the report, Ms Crawford said Mr Pigeon had two pre-existing conditions — coronary artery disease and hepatic steatosis — which made him ‘more susceptible’ to paracetamol toxicity. 

Hepatic steatosis, or fatty liver disease, occurs when excess fat builds up in the liver, and often has minimal symptoms.

Both increase toxicity by increasing blood pressure and raising the production of the toxic metabolite NAPQI, respectively. 

In the report, Ms Crawford said Mr Pigeon had two pre-existing conditions — coronary artery disease and hepatic steatosis — which made him ‘more susceptible’ to paracetamol toxicity

Ms Crawford said 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 ‘who are authorised or entitled to supply medicinal products to the public’, she added. 

Wholesalers should ‘comply’ with these guidelines by ‘requesting and checking a customer’s status’.

A copy of her report was also sent to the Mr Pigeon’s family, the UK medicines watchdog the Medicines and Healthcare Products Regulatory Agency (MHRA), as well as the chief coroner. 

All organisations ‘have the power’ to ‘prevent future deaths’, Ms Crawford warned. 

In a seven-page response to the report, Booker offered its ‘sincere condolences’ to Mr Pigeon’s friends and family.

The wholesaler told the coroner that it was not aware of the ‘tragic circumstances of Mr Pidgeon’s death’ and it was ‘unfortunate that Booker was not invited to make representations at the inquest’.

At the time of his death, Mr Pidgeon had held an account with Booker ‘for over 20 years’, meaning ‘the qualification system for members would have been different’ when he joined.

Given the  significant period of 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’, however this was purely ‘speculative’.

Booker also said that ‘various aspects’ of its systems have changed since 2022 and ‘has a stringent qualification process in place for customers which requires them to prove they are entitled to supply to the public’. 

‘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. 

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