Recurring concern

Inadequate controls on supplying medicinal products to unauthorised customers

First to latest report 27 Mar 2017 — 11 Aug 2025

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
9

What this concern includes

Includes failures in regulatory, supplier or pharmacy controls specifically intended to verify customer authorisation or entitlement before medicinal products are supplied, or to enforce compliance with those supply requirements, including online-prescription guidance and wholesale medicinal-product transactions.

What is not included
  • Excludes age and identity verification before online access to restricted medicines where authorisation or entitlement to supply medicinal products is not the concern.
  • Excludes medication quantity, prescribing, dispensing, administration or clinical-treatment failures that do not concern whether the customer is authorised or entitled to receive or supply medicinal products.
  • Excludes generic regulatory, guidance or sanctioning deficiencies not specifically tied to controls on medicinal-product supply to unauthorised customers.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Paul Pidgeon · 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

    Paul Pidgeon was found deceased at home on 20 March 2022 after deliberately overdosing on paracetamol the previous day. His death was caused by paracetamol toxicity, with coronary artery disease and hepatic steatosis contributing. The Coroner was concerned that Booker in Wimbledon, and potentially Booker more widely, may have sold bulk quantities of medicinal products to customers not authorised or entitled to supply them to the public, creating a risk of future deaths.

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    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 customers’ authorisation or entitlement before supplying medicinal products

    Wider context from the report

    “The Guidelines for the Good Distribution Practice of Medicinal Products for Human Use (2013) state that wholesale suppliers must ensure that they supply medicinal products only to those who are themselves in possession of a wholesale distribution authorisation or who are authorised or entitled to supply medicinal products to the public. The Guidelines go on to set out measures by which wholesalers can comply with that duty, including by requesting and checking a customer’s status. Mr Pidgeon was a mechanic and his business account with Booker was in relation to his garage business. His business did not involve the onward supply of medication to the public. However, he was able to bulk purchase both paracetamol and ibuprofen from Booker in Wimbledon on two occasions. It does not appear that any checks were carried out to confirm his status prior to the sales. ████████ ████████████████████████████████████████ The Coroner is therefore concerned that Booker in Wimbledon, and therefore potentially Booker more widely, may be selling medicinal products to customers who are not authorised or entitled to supply them to the public. Given, the potential for this to result in significant amounts of medicines being sold in single transactions, the Coroner is concerned that this gives rise to the risk of future deaths. ”

    Source location

    Paul Pidgeon · Prevention of Future Deaths report
    Page 3 · concerns

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    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

    Operate a medicine-specific customer qualification process requiring documentary verification, category checks, management sign-off and recorded entitlement before permitting purchases.

    Verbatim wording from the response

    “4.4. In order to purchase medicines from a Booker branch, Booker's medicine customer qualification process requires customers to be qualified and verified specifically for the purchasing of medicines prior to being able to do this/ or to continue to do this. This is over and above the process customers need to undergo to obtain a trade card. Booker's current system for customers qualifying to purchase medicines in its branches has been in place since April 2025.”

    Source location

    Response from Brooker Group Limited
    Page 4 · response
    Published 31 October 2025

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    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

    Block medicinal-product purchases at the till for non-qualified customers without allowing staff to override the block.

    Verbatim wording from the response

    “b) A till block was introduced in September 2025 so that any customers trying to buy medicines when they are not validated to do so will automatically be blocked from making the purchase. There is no option for branch staff to overwrite the till block. This will prevent anyone who isn't categorised on the Booker system as a retailer, school nurse or care home will not be able to purchase medicines.”

    Source location

    Response from Brooker Group Limited
    Page 2 · response
    Published 31 October 2025

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    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

    Require customers entering the restricted medicines area to sign a declaration confirming their registration to purchase medicines.

    Verbatim wording from the response

    “c) Any customers who are visiting the restricted medicines area of the branch are required to sign a medicine customer declaration form to confirm they are appropriately registered to purchase medicines before leaving the store.”

    Source location

    Response from Brooker Group Limited
    Page 2 · response
    Published 31 October 2025

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    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

    Update and distribute the Branch Manual with medicine-control procedures, including the requirement for relevant colleagues to confirm they understand and will follow them.

    Verbatim wording from the response

    “3.1. Booker has a Branch Manual in place for Medicine Controls which is held in paper copy in each of its branches as well as being available to colleagues online via our colleague communication system. Version 17 of the Branch Manual was in place at the time of Mr Pidgeon's purchases in 2022, and the current version (version 20) was issued on 15 August 2025.”

    Source location

    Response from Brooker Group Limited
    Page 3 · response
    Published 31 October 2025

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    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

    Recheck customers’ entitlement to purchase medicines every two years, covering historical accounts and new registrations from January 2026.

    Verbatim wording from the response

    “d) Booker's branch manual has been updated with the requirement for branch staff to recheck the validity of customers registered to buy medicines every 2 years, starting from January 2026. This process would include any historical accounts as well as any new registrations going forward.”

    Source location

    Response from Brooker Group Limited
    Page 2 · response
    Published 31 October 2025

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    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

    Provide annual online GDP training with a competency test and restrict medicine sales duties to colleagues achieving the required pass mark.

    Verbatim wording from the response

    “6.1. All Booker colleagues who are employed at a branch stocking medicinal products must undergo medicines compliance training. This training is undertaken as part of colleagues’ mandatory inductions when they first join Booker, and in 2022, there was a requirement for it to be refreshed every three years.”

    Source location

    Response from Brooker Group Limited
    Page 6 · response
    Published 31 October 2025

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    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

    Operate branch medicine audits by Responsible Persons, documenting deviations through corrective and preventive action plans.

    Verbatim wording from the response

    “7.1. A vital part of the QMS system is the ability for the Company to monitor and audit that its systems have been implemented and are working as expected.”

    Source location

    Response from Brooker Group Limited
    Page 6 · response
    Published 31 October 2025

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    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

    Conduct periodic senior-management and Responsible Person reviews of Quality Management System objectives, corrective actions and process improvements.

    Verbatim wording from the response

    “7.4. Lastly, we have in place a periodic management review of the QMS objectives by Senior Management, the RP and relevant Area Leads to monitor the effectiveness of the system and implementation of CAPA Plans or improvements such as improving robustness of the qualification process.”

    Source location

    Response from Brooker Group Limited
    Page 6 · response
    Published 31 October 2025

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    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

    Control access to medicinal products through locked storage, staff accompaniment and prominent notices restricting bulk sales to appropriately qualified trade customers.

    Verbatim wording from the response

    “5.1. All Booker sites which sell restricted products such as medicines and tobacco have a lockable, designated room in which those products are stored and displayed for sale. At the Wimbledon branch, this room is sealed off from the main floor of the branch by a lockable roller shutter. The roller shutter should remain closed unless a customer with the adequate customer qualification to enable them to purchase restricted products requests for a trained member of staff to open it for them and accompany them in the room while they make their purchases. In this way, Booker prevents not only access by customers who are not allowed to purchase restricted products but removes them from sight to other customers as well.”

    Source location

    Response from Brooker Group Limited
    Page 5 · response
    Published 31 October 2025

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    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

    Existing QMS changes, including tighter qualification and a till block, are considered sufficient; no further action is required.

    Verbatim wording from the response

    “8.3. We trust the above satisfies you that Booker has in place an effective system that complies with the GDP to ensure customers who are not authorised or entitled to supply medicines to the public are not able to purchase them from any Booker branches. Given the changes that Booker has already implemented in this area to strengthen its QMS, we hope this demonstrates that no further action is required beyond those changes already detailed above. We regret that we did not have the opportunity to provide the above information during the course of the inquest.”

    Source location

    Response from Brooker Group Limited
    Page 7 · response
    Published 31 October 2025

    Open published response

  2. Manchester South

    AI-generated summary

    Steven Thomas Fone · 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

    Steven Fone died on 31 October 2016 following consumption of a fatal combination of tramadol, cocaine, amitriptyline, methadone, pregabalin and heroin. The concern raised was that a pharmacy allowed customers to collect one another’s prescriptions, potentially enabling stockpiling of medicines with a risk of harm or death.

    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 control and document consent for interchangeable collection of prescriptions

    Wider context from the report

    “During the course of evidence at the Inquest I was informed that Adams Pharmacy permitted three separate customers in receipt of prescriptions to interchangeably collect each other's prescriptions. No documentation was before the court to confirm whether consent had been given by any customer. I would like to know whether this practice is approved of by the relevant regulator of pharmacies. It seems to me this practice could be open to abuse and facilitate stock-piling leading to an increased risk of harm or death to those prescribed medicines which have the propensity to be fatal if taken outside the recommended guidance. ”

    Source location

    Steven Thomas Fone · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026