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A coroner’s report has called for the government to take action on the supply of medicines online, following the death of a patient who purchased “huge” quantities of zopiclone.
The ‘Prevention of future deaths report’, published on 4 June 2024 by coroner Isabelle Thistlewaite, investigated the death of 64-year-old Nigel Dixon in February 2023, following an overdose from two controlled drugs — morphine, which was obtained through an NHS prescription, and zopiclone, which was purchased online.
Thistlewaite concluded that the online purchase contributed to the death and said that the availability of these “powerful drugs” in such large quantities is “gravely concerning”.
Zopiclone is a class C controlled drug, indicated for short-term treatment of insomnia. Prolonged use of the hypnotic drug can lead to abuse and dependency issues.
The report further highlighted the lack of regulation in the online supply of zopiclone, with no communication to the patient’s GP in this case.
The report stated that the GP who gave evidence at the inquest said that a “huge” amount of zopiclone was provided to the patient, in larger doses than would ordinarily be prescribed.
It also raised concerns around the safety and quality control of the medicines being supplied online.
Thistlewaite noted that other coroners have voiced concerns about the online supply of medicines, particularly in relation to the gaps in regulations, and recommended that government action is needed to prevent future deaths.
An analysis by The Pharmaceutical Journal of regulation 28 reports — which are legally required from a coroner when they believe action should be taken by a person, organisation, local authority or government department or agency to prevent future deaths — published on the Courts and Tribunals Judiciary website, revealed that there were 20 reports published between 2013 and 2023.
In these, coroners warn that having “freely marketed” drugs available online with “no regulation” in their supply “clearly constitutes an ongoing risk to the lives of other vulnerable people”.
These warnings were sent to a variety of regulators, government bodies and agencies, including the Home Office, Medicines and Healthcare products Regulatory Agency, Department of Health and Social Care, General Pharmaceutical Council and National Crime Agency.
Commenting on Thistlewaite’s report, Jay Badenhorst, director of pharmacy at the Pharmacists’ Defence Association, said: “Unfortunately, this is another example of a patient tragically losing their life due to systemic failures of a lack of regulation whereby patients can obtain dangerous drugs online.
“Allowing patients to have medicines prescribed on a ‘product-led’ basis through online pharmacies and an evident lack of regulation will continue to have disastrous effects on patients’ lives,” he added.
“This practice must not be ignored, and the coroner’s report, similar to previous incidents, must be a wake-up call to those setting regulations and safeguarding practices.”
Wing Tang, head of professional guidance, standards and patient safety at Royal Pharmaceutical Society, said: “The accessibility offered by online services must be matched by effective regulation against existing regulatory and professional standards, so the public is assured of receiving high quality healthcare wherever and however it is accessed.
“Pharmacists play a vital role in ensuring the safe and appropriate use of medicines, including careful assessment of potential interactions, and it is important they are supported by the system to do so,” said Tang.
In March 2022, an Online Safety Bill was introduced in the House of Commons, requiring social media platforms, search engines and other apps to tackle illegal activity, including offences under the Misuse of Drugs Act 1971, such as the unlawful supply of controlled drugs and the inciting of any other offence under the Act.
The Bill gives regulator Ofcom to power to fine companies failing to comply with laws up to 10% of their annual global turnover, force improvement to their practices and block non-compliant sites.
