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First report 4 Jun 2024•Latest report 4 Jun 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. 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. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Sale of online drugs in doses and quantities larger than ordinarily prescribed

    Wider context from the report

    “Mr Dixon was able to purchase ████████ Zopiclone tablets ████████ online from a company ████████ The GP who gave evidence at the inquest described this as a “huge” amount of the drug. She confirmed that she would only prescribe 28 days’ worth of ████████ tablets in one go (████████ Mr Dixon was able to purchase). The selling of tablets which are a larger dose and in a much larger quantity than would ordinarily be prescribed online risks an accidental or intentional overdose of the drug and also risks the drug being sold on the black market. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of regulation of online supply of powerful drugs

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform the purchaser’s GP practice of online drug purchases

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of safety and quality control for drugs supplied online

    Wider context from the report

    “The evidence of the GP is it is hard to prescribe safely to people who are supplementing their prescription drugs with online purchases. Further, she raised concerns about the safety and quality control of the drugs being supplied. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to control duplicate, excessive or frequent online drug purchases

    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. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026