A coroner investigating an overdose death has raised ‘grave concerns’ about online drug sales, including the lack of communication with a patient’s GP.

The same case suggested failings in communication between hospital and community pharmacy, which the coroner said she was satisfied have since been resolved.

'Huge' quantity of drugs bought online

Last month, coroner Isabel Thistlewaite issued a ‘prevention of future deaths report’ to the health secretary following the death of a man in Leicestershire.

Nigel Dixon died in February 2023 from an overdose of two medications – morphine, which he obtained through an NHS prescription, and Zopiclone, which the coroner concluded he had purchased from an online company.

The GP who gave evidence at his inquest described the quantity of drugs he bought online as ‘huge’ and beyond what she would ordinarily prescribe.

She also said it is difficult for GPs to ‘prescribe safely’ for patients who are purchasing other drugs online, and that this particular company had not contacted her practice to discuss the drug’s ‘suitability’, Mr Dixon’s medical history or even to inform them of the purchase.

Ms Thistlewaite concluded that the drugs Mr Dixon purchased ‘contributed to his death’ and that the online company offered him ‘no protection’ for a number of reasons, including the lack of contact with his GP.

'Seems to be no regulation' around online drug sales

In her report to the health secretary, she 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.

‘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.

‘In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their 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.’

In particular, the coroner was concerned about the dosage of the tablets Mr Dixon was able to purchase, which was ‘larger than those that a GP would prescribe’.

According to Ms Thistlewaite, other coroners have raised similar concerns about online drug sales, and specifically the ‘gaps in regulation’.

She called on health secretary Victoria Atkins, as well as secretary of state for digital, culture, media and sport Lucy Frazer, to take actions to prevent similar future deaths.

Hospital discharge letter 'not actioned'

Mr Dixon was a 64-year-old army veteran who had a past medical history of physical and mental health issues, including depression, suicide attempts, being sectioned, chronic alcohol misuse, and an opioid dependence.

He was in the process of being weaned off morphine with support of his GP when he was admitted to hospital on 3 February 2023 for an opiate overdose.

As an inpatient, he experienced an ‘abrupt cessation’ of morphine. But when he was discharged from hospital on 7 February,  the hospital discharge letter 'was not actioned'.

Mr Dixon was therefore able to access one weeks’ worth of morphine which had been prescribed to him and the prescription post-dated prior to his stay in hospital.

According to the coroner's report, he was later found dead at home on 13 February.

'Improvements' made to hospital-community pharmacy communication system

Following Mr Dixon’s death, University Hospitals of Leicester NHS Trust have made ‘improvements’ to their pharmacy system to ensure hospital pharmacists communicate the cessation of drugs like morphine to community pharmacies.

The coroner was satisfied, ‘on the balance of probabilities’, that this would prevent a similar situation arising again.

Mr Dixon had no prescription from his GP for Zopiclone at the time of his death, but he had been ‘honest with his GP’ about the fact he was purchasing this drug online ‘to supplement his prescriptions’.

The report said: ‘In August 2017 he advised his GP that he was taking [REDACTED] Zopiclone tablets every two weeks, this is 6 times the licenced amount of Zopiclone.’

His family provided documents to the coroner showing that he purchased drugs online in the weeks before he died, and the coroner concluded that the Zopiclone found in his system by the post-mortem examination was supplied by the same online company.

The Department of Health and Social Care confirmed it will respond to the coroner’s report in due course, and that its sympathies are with Mr Dixon’s family and friends.

Last year, the Pharmacists' Defence Association (PDA) warned pharmacists working as online prescribers to beware the ‘red flag’ of a patient refusing to allow them to contact their GP.

And it urged the General Pharmaceutical Council (GPhC) to extend guidance relating to the safe online prescribing of high-risk medicines to all medicines that are highly toxic in overdosage.

In May, the GPhC told The Pharmacist it was working to update its guidance to provide more clarity for pharmacy professionals working in online settings, following concerns about the use of online questionnaires.

A version of this article first appeared on our sister publication Pulse.