Trade Account Allowed Bulk Purchase of Painkillers Before Fatal Overdose
A South London mechanic was able to use his business trade card to purchase painkiller medication in bulk from a major high street wholesaler, bypassing standard retail restrictions. This system failure occurred before his tragic death from an overdose and has prompted a comprehensive safety review across the wholesale chain.
Paul Pidgeon, who ran Southfields Garage in Wandsworth, was found dead at his home in East Clandon, Surrey, in March 2022. Empty packets of painkillers surrounded his body. The subsequent inquest heard that he had deliberately taken an overdose the previous day, though his precise intentions regarding taking his own life remained unclear.
Coroner Identifies Dangerous Gap in Wholesaler Procedures
Surrey's Assistant Coroner, Anna Crawford, conducted the investigation into Mr Pidgeon's death. Her report revealed that staff at the Booker Wholesale branch in Wimbledon allowed Mr Pidgeon to make bulk purchases of painkiller medication on two separate occasions without verifying his authorisation.
Mr Pidgeon's garage business was not permitted to buy or supply medication to the public. Despite this, the inquest found that Booker staff failed to check his business account status. Coroner Crawford described this lapse as exposing a "dangerous" gap in the company's procedures that could enable other non-medical businesses to make similar purchases.
The coroner formally expressed concern that such unchecked sales could lead to future deaths across Booker's national network of branches. She subsequently required operator Booker Group Limited to explain how it would prevent similar tragedies from occurring.
Wholesaler Implements Strict New Safety Measures
In its response to the coroner, Booker acknowledged that weaknesses in its older systems had permitted the sale to Mr Pidgeon. The company emphasised that these issues have now been resolved and that its updated procedures meet all regulatory standards.
The new safety measures implemented by Booker include:
- Mandatory proof of authorisation for customers purchasing medicines
- Full review of verified accounts every two years to confirm eligibility
- An automated till block introduced in September that prevents unqualified customers from completing medicine purchases
- Secure, locked rooms for medicine storage accessible only with trained staff assistance
- Annual compliance training and competency testing for staff handling medicine sales
- Regular audits by a 'responsible person' to ensure branch compliance with national guidelines
Booker stated that the automated till block cannot be overridden by staff, ensuring that only approved retailers, care homes, and schools can purchase medicines. The company also hired an external consultant to help improve its practices in this area.
The wholesaler revealed it had not been aware of the inquest until receiving the coroner's report in August this year, as it had not been invited to participate as an 'interested person'. Booker extended its condolences to Mr Pidgeon's family and affirmed its commitment to improving safety and maintaining strict compliance across its network.
The coroner has shared her findings with the national medicines regulator and Mr Pidgeon's family, concluding a case that has triggered significant changes in how major wholesalers control access to medicinal products.
