Susan Marie Karakoc · Prevention of Future Deaths report

On 7 March 2024, I commenced an investigation into the death of Susan Marie Karakoc.

The investigation concluded at the end of the inquest on 28 November 2024.

The conclusion of the inquest was a narrative conclusion:

Susan Marie Karakoc sought to treat her symptoms of fibromyalgia with ████████ and ████████ which she obtained from websites selling prescription medication off-label. Susan had levels of ████████ associated with fatalities and ████████ at a potentially toxic level. Those medications taken together acted synergistically to depress Susan’s cardiorespiratory system which led to her suffering hypoxic brain injury which in turn caused her to suffer multiple organ failure which led to her death.

On 1 December 2023, Ms Karakoc collapsed at her home address. She was found by a family member and transported to hospital by ambulance. Investigations at hospital found Ms Karakoc had suffered a hypoxic brain injury which was not survivable. Ms Karakoc died on 2 December 2023.

Following Ms Karakoc’s death, toxicological examination revealed that the catalyst for the chain of events leading to Ms Karakoc’s death was ████████ and ████████ toxicity. Ms Karakoc was not prescribed either of these medications by her General Practitioner and the General Practitioner was unaware of Ms Karakoc taking those medications.

Ms Karakoc’s family provided evidence which proved that Ms Karakoc obtained these medications from online sources via websites set up to sell prescription medication off-label. Ms Karakoc made over 100 purchases of ████████ and ████████ in a period of a little over a year. The ready availability of medications such as these to purchase from websites circumvents the patient safety measures in place and places vulnerable persons at risk of death. This represents a real and ongoing risk of future deaths occurring.

1. There is evidence of search engines readily returning websites which sell prescription medications, including those that sell highly addictive sleeping tablets and painkillers which can and do cause fatalities. I am concerned how readily search engines return websites such as these;

2. I am concerned that the current system for monitoring the legitimacy of supply chains for medications available in England and Wales via prescription is not preventing the ready supply of such medications online;

3. There is evidence that banks form a legitimate part of the supply chain, and that this is crucial to the functioning of these criminal enterprises. I am concerned that the current system for detecting such criminal enterprises and alerting the relevant authorities is not effective.

I am not reassured that necessary actions to address the serious issue identified are in place.