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Coroner calls for online drug prescribers to communicate with patients’ GP

Coroner calls for online drug prescribers to communicate with patients’ GP

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

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. 

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. 

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. 

The coroner said he was being monitored ‘closely’ by his GP, and they had worked together to reduce the number of his prescription drugs, including cessation of his Zopiclone prescription.

The circumstances of Mr Dixon’s death:

  • 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;
  • He experienced an ‘abrupt cessation’ of morphine as an inpatient;
  • He was discharged from hospital on 7 February, but the hospital discharge letter was not actioned meaning he was able to access one weeks’ worth of morphine which had been prescribed prior to his hospital stay;
  • He was found dead at home on 13 February.

Source: Coroner’s report

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, a pharmacist membership organisation warned those working as online prescribers to beware the ‘red flag’ of a patient refusing to allow them to contact their GP.

The Pharmacists’ Defence Association also urged the pharmacist regulator to extend guidance relating to the safe online prescribing of high-risk medicines to all medicines that are highly toxic in overdosage.


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Please note, only GPs are permitted to add comments to articles

Nicholas Sharvill 4 July, 2024 2:02 pm

What is almost unbelievable is that none of the regulatory authorities seem to care . by this I include the GMC, CQC and the Royal Pharmaceutical society and its professional bodies. All these people have a prescription issued by a licensed prescriber and since we have left the EU that means UK registered and issued by a UK registered pharmacy. Having personally tried to raise specific concerns n the past one realises this is not on their radar even though visible in plain site. Should a nurse in Hospital make an error on just one pill they are hounded by the authorities but not seemingly if in the community by those trusted to be professional

Not on your Nelly 4 July, 2024 4:25 pm

I am afraid informing the GP would not help in any way either. The consultation and prescription was between the private provider and a patient, so all liability lies between them. Why are GPs with nothing to do with this death being dragged into this? Where in the contract does it say we are required to police patients private prescriptions or private consultations. Just for once, leave GPs out of this and deal with the problem. We can’t be made the scapegoat or responsible for all prescribing, operating or anything that happens to any patient who is registered with us.

Just My Opinion 4 July, 2024 5:15 pm

So now we are to police the private providers as well?
And it’s our fault if a patient dies of an overdose from a medication that a private company supplied to them?
And they wonder why GP numbers continue to fall.

David Church 4 July, 2024 10:11 pm

Not sure what the Coroner was on about here. Surely they knew that it is alreasdy a requirement by the GMC that the prescriber contact the GP? This is stated quite clearly in GMC guidance, that prescriber is ‘Practicing Medicine’, and, as such, they would be in breach of their Registration if they fail to communicate with the patient’s Registered General Medical Practitioner or responsible Consultant (for an inpatient) ? Persons ‘Practicing Medicine’ by prescribing who have not informed the GP, should have their Registration and prescribing rights cancelled for illegal Practice of Medicine.
No, it would still not prevent manipulative patients killing themselves, or other people, but it would reduce the likelihood of them getting through that short period before they are found out.
GMC should take immediate action on this Coroner’s report.

Lochend Lad 5 July, 2024 9:34 am

Having tried to raise an issue with the General Pharmaceutical Council years ago they ignored my letter and did not respond to a follow up email. They apparently do not have any local or national “Performers List” procedures. So if a concern does not reach the threshold for erasure, nothing happens. Transparent they are not.
Compared to GPs pharmacists face nowhere near the multiple layers of jeopardy GPs face every day. Considering the amount of “clinical” work they now do its a worry.
And if “informing the GP” hands over clinical responsibility that is a major concern.

Bonglim Bong 5 July, 2024 10:11 am

I’m not sure it is for policing what the private provider. But safety for what you, as an NHS GP do, after the private provider has done their prescription.

There needs to be better use of technology to make this safer:
– Sharing a code with the private provider so they can have immediate read-only access to the medical record. In the same way you share a code with the car rental company who checks if you have 9 penalty points or a valid licence.
– A standard practice of not being able to opt out of sharing the outcomes of private consultations with the NHS GP. At the moment they need the patient’s permission. Most don’t have policies of declining service to those who decline permission. That is not to police the decision being made, but to make future prescriptions by the NHS GP (or other private companies with read only access to the notes) safe.

A B 5 July, 2024 1:26 pm

Who signed the prescription? This person holds some liability for this mans death

Lochend Lad 5 July, 2024 1:46 pm

At face value the original prescriber has full legal responsibility for their prescribing. If that information is shared with the GP, and the GP fails to take action such as intervening to prevent drug misuse, they will share some responsibility if the patient suffers harm. In effect it creates a responsibility to monitor (or police) third party prescribing. In the event of an adverse outcome the GP is invariably an easier target than an online pharmacist/prescriber.