Nigel Walter DIXON · Prevention of Future Deaths report

On 20 February 2023 I commenced an investigation into the death of Nigel Walter DIXON aged 64. The investigation concluded at the end of the inquest on 4 June 2024.

The conclusion of the inquest was:

Drug related death

The cause of death was established as:

I a Morphine and Zopiclone Toxicity
I b
I c

II

Mr Dixon was a 64 year old male who lived alone. A visitor to his property was unable to rouse him on Monday 13 February 2023. Entry was gained by the Fire Service and Mr Dixon was found dead inside.

Pre-amble

Mr Dixon was a 64 year old male, an army veteran who served his country as part of an elite unit. He had a past medical history including physical and mental health issues including depression, suicide attempts, being sectioned, chronic alcohol misuse and an opiod dependence.

Mr Dixon’s GP monitored him closely in the community and they worked together to reduce the number of prescription drugs Mr Dixon was taking, stopping the prescribing of Zopiclone then Diazepam. Mr Dixon was in the process of being weaned off morphine with the support of his GP when he was admitted to hospital on 3 February 2023 for an opiate overdose.

Whilst an inpatient Mr Dixon had an abrupt cessation of his morphine use.

Mr Dixon was discharged from hospital on 7 February 2023. The hospital discharge letter was not actioned and Mr Dixon was able to access one weeks’ worth of morphine which had been prescribed to him and the prescription post-dated prior to his stay in hospital.

Mr Dixon was found dead at home on 13 February 2023 and at post-mortem his cause of death was found to be 1a) Morphine and Zopiclone Toxicity.

Mr Dixon was able to access one weeks’ worth of morphine from his community pharmacy when he was discharged from hospital. I heard evidence at inquest of improvements to the use of a system at the University Hospitals of Leicester NHS Trust, PharmOutcomes, which will, on the balance of probabilities, prevent this situation arising again by ensuring that the Hospital Pharmacist communicates the cessation of drugs like morphine to community pharmacies.

Mr Dixon was honest with his GP about the fact he purchased drugs online to supplement his prescriptions. In August 2017 he advised his GP that he was taking ████████ Zopiclone tablets every two weeks, this is 6 times the licenced amount of Zopiclone.

Mr Dixon was not being prescribed Zopiclone at the time of his death, his GP stopped prescribing it to him in 2017.

Mr Dixon’s family provided me with documentary evidence of him purchasing drugs online before he died, one of those documents is a receipt dated 1 February 2023 ████████
████████. I found, on the balance of probabilities, that the Zopiclone in Mr Dixon’s system at the time of his death was supplied by ████████

Concerns

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.

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.

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.

I have concerns about the dosage of the tablets purchased by Mr Dixon which are larger than those that a GP would prescribe, and also the quantity of the tablets that Mr Dixon was able to purchase.

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.

In short, there was no protection offered to Mr Dixon by the online company who sold him these, and other drugs, and it is clear that the drugs purchased from the company have contributed to his death.

I understand that other Coroners have raised concerns about the supply of drugs online, and in particular in relation to the gaps in regulation of that industry in other PFD reports. As detailed above, I share those concerns.