Recurring concern

Failure to verify patient suitability before online sale of restricted medicines

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First reported 15 Sep 2016•Latest report 23 Apr 2025

Definition

What this concern includes

Includes failures of controls specifically dedicated to verifying patient suitability before online sale or supply of prescription-only or controlled medicines, including checks of medication access, medical history and related patient-provided information before relying on self-certification or dispensing.

Not included

  • Excludes age and identity verification alone where patient suitability or medical-history verification is not also the concern; that issue is covered by the existing online restricted-medicine age and identity parent.
  • Excludes generic prescribing, dosage, diagnosis, counselling or medication-supply deficiencies unless they directly concern pre-sale verification of patient suitability.
  • Excludes failures in face-to-face or ordinary clinical medication assessment where online restricted-medicine sales are not the named process.
  • Excludes generic questionnaire integrity or self-certification failures unrelated to online sale of restricted medicines.
Reports
5

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3
NHS England3
Department for Digital, Culture, Media and Sport2
Care Quality Commission1
Department for Digital, Culture, Media & Sport (2017 to 2023)1
General Medical Council1
General Pharmaceutical Council1
H & R Healthcare Limited1
Recipient name withheld1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Ceredigion

    AI-generated summary

    Christopher Brazil · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher Brazil had physical pain, sciatica and poor mental health, and sourced additional medicines and drugs from unlawful online providers. He died in August 2022 after unintentionally overdosing on benzodiazepines. The concerns included the accessibility and legitimacy of unregulated websites, unsafe or counterfeit medicines, inadequate checks of medical history, dosage guidance, safeguards, age and identity verification, and rapid delivery.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient or absent verification of patient medical history before medication sales

    Wider context from the report

    “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6) (2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications (3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs (4) There is a lack of guidance regarding dosage (5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers (6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs (7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources. ”

    Source location

    Christopher Brazil · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Rutland and North Leicestershire

    AI-generated summary

    Nigel Walter DIXON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Nigel Walter Dixon, a 64-year-old man who lived alone, was found dead at home on 13 February 2023 after being unable to be roused. His cause of death was morphine and Zopiclone toxicity. Concerns included his access to morphine after hospital discharge and the online supply of large quantities and dosages of Zopiclone without adequate checks, communication with his GP, or safeguards.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to establish the suitability of online drug purchasers

    Wider context from the report

    “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. There seems to be no system for establishing the suitability of the purchaser, nor a system to limit the amount or frequency of medication being purchased. ”

    Source location

    Nigel Walter DIXON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess online drug suitability against the purchaser’s medical history

    Wider context from the report

    “The evidence of the GP was that the company who supplied these drugs to Mr Dixon did not contact the GP Practice to discuss their suitability or check Mr Dixon’s medical history, nor did they inform the GP’s Practice of the purchase. ”

    Source location

    Nigel Walter DIXON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Leicester City and South Leicestershire

    AI-generated summary

    Jamie Francis O'Connor · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to protect questionnaire answers from alteration

    Wider context from the report

    “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

    Source location

    Jamie Francis O'Connor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Exeter and Greater Devon

    AI-generated summary

    Karl James Willis · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Karl James Willis was found deceased at home, with toxicology showing amitriptyline at a concentration within the reported fatal range and morphine sufficient to increase its toxicity. The inquest recorded the medical cause of death as aspiration pneumonitis and amitriptyline and morphine toxicity, with a conclusion of misadventure. Concerns included online access to amitriptyline without adequate checks, the ability to provide inaccurate information, and the option not to inform the patient’s GP.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to check patients’ appropriate access to medication before self-certification

    Wider context from the report

    “(2) Permitting the patient to “self certify” without any checks he can appropriately access this medication can allow the patient to give inaccurate answers, and therefore the questionnaire is open to deliberate abuse by those most vulnerable who have addiction problems ”

    Source location

    Karl James Willis · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Private consultations, private-only clinicians and online prescribing fall outside the Board’s jurisdiction or control.

    Verbatim wording from the response

    “In choosing to access private health care, a patient is stepping outside the NHS, as a result, the Board has no jurisdiction over private consultations and none of the Board’s powers relating to community pharmacy, prescriptions or regulation would apply.”

    Source location

    2018-0256-Response-by-NHS-England
    Page 2 · response
    Published 26 September 2018

    Open published response

  5. Brighton and Hove

    AI-generated summary

    Philip Richard David BREATNACH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Philip Richard David Breatnach's circumstances are referred to in the Record of Inquest. The concerns relate to online applications for medication, inadequate checking of answers and failure to contact his GP, and the prescribing of Dihydrocodeine by a prescriber who had not seen him, including concerns about the quantity, suitability for migraine, and dosing instructions. The inquest concluded with a finding of MISADVENTURE (DEPENDENCE ON DRUGS).

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to thoroughly check online medication application forms

    Wider context from the report

    “(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

    Source location

    Philip Richard David BREATNACH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with partner agencies to consolidate regulatory and professional guidance on online prescribing and medicine supply.

    Verbatim wording from the response

    “The group agreed to work together to assimilate current regulatory and professional guidance into one place so there is greater clarity regarding good practice in respect of online prescribing and supply of medicines giving particular guidance on medicines such as controlled drugs and antibiotics.”

    Source location

    2016-0330-Response-by-NHS-England
    Page 2 · response
    Published 18 September 2016

    Open published response
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Data last updated 7 September 2026