Table 1

Sixteen reports of 17 deaths attributed to the use of medicines or non-medicinal compounds purchased online (created by the authors)

AgeSexDate of deathDate of inquestDate of reportAddressee(s)Date of reply* (delay)Verdict†Contributory factors
33F24 April 201317 February 201426 February 2014The Ministry of JusticeNone‡Suicide with pentobarbitalMental health problems (borderline emotionally unstable personality disorder and hypochondriacal disorder)
41F22 April 20146 August 20147 August 2014Camden & Islington NHS Foundation Trust2 October 2014
(56 days)		Overdose of amitriptyline, intention unclearMental health problems (unstable personality disorder, depression and obsessive–compulsive disorder)
34M5 June 201414 October 201420 October 2014The Secretary of State for Health15 July 2015 (268 days)Unintentional death from overdose of diazepam, codeine, and alcohol while intoxicated; the codeine was obtained onlineMental health problems (mood swings, anxiety, and poor impulse control)
Drug dependence/abuse (alcohol)
NSF6 December 201627 October 201730 October 2017

  1. The Home Office.

  2. The Department of Health.

  1. None.

  2. 8 January 2018 (70 days).

Overdose with unspecified medicines, prescribed and purchased OTC and online, intention unknownMental health problems (borderline unstable personality disorder and insecure attachment)
21F15 February 201714 February 201815 February 2018The Secretary of State for Health24 April 2018
(68 days)		Suicide with dinitrophenolMental health problems (unspecified)
22M28 July 201817 September 201923 September 2019

  1. Department of Environment, Food and Rural Affairs.

  2. The Health & Safety Executive.

  3. The Chemical Business Association.

  1. None.‡

  2. None.‡

  3. None.‡

Suicide by cyanide poisoning from using electrobrightening saltsMental health problems (Asperger’s syndrome)
28M26 February 201911 November 201918 November 2019The Village Medical Centre, LittleboroughNone‡Died from the (presumed unintentional) combined effects of individually non-toxic amounts of alcohol and illicit drugs, including diazepam, purchased online after a course of chlordiazepoxideMental health problems (chronic anxiety)
Drug dependence/abuse (alcohol and benzodiazepines)
22F22 July 20195 December 20195 December 2019The Medicines and Healthcare products Regulatory Agency
[Also the suppliers of aspirin and ibuprofen])		27 February 2020
(84 days)		Overdose in response to voices in her head, without suicidal intent, of aspirin (400×300 mg) and ibuprofen (80×400 mg) (both obtained online) + zopiclone, loperamide, morphine, sertraline, amitriptyline, and phenoxymethylpenicillin (all prescribed)Mental health problems (anxiety and depression)
41F28 July 201711 November 201918 November 2019The Secretary of State for Health and Social Care27 February 2020
(101 days)		Chronic pancreatitis secondary to codeine, both prescribed and purchased OTC and onlineChronic pain
Drug dependence/abuse (opioids)
24M30 June 201417 March 201530 March 2015The Home Secretary21 May 2015
(52 days)		Deliberate overdose of drugs obtained via the internet: ketamine, heroin, diazepam, and dextromethorphan; also obtained alprazolam, methylphenidate, morphine, syringes, and cannulae via the internetDrug dependence/abuse (benzodiazepines)
NSM9 February 20156 May 20158 May 2015The Advisory Council on the Misuse of DrugsNone‡Accidental death from ingestion of acetylfentanyl while attempting to discontinue heroinDrug dependence/abuse (opioids)
31MMarch 201624 August 201615 September 2016

  1. NHS England.

  2. The foreign supplier and its UK branch.

  1. 24 November 2016 (70 days).

  2. None.‡

Overdose with dihydrocodeineDrug dependence/abuse (opioids)
51F4 June 20181 September 201824 October 2018

  1. NHS England.

  2. The General Pharmaceutical Council

[Also the online supplier of tramadol abroad])

  1. 13 February 2019 (112 days).

  2. None.

Suicide with alcohol + 210 tablets of tramadolDrug dependence/abuse (alcohol)
23M24 July 201326 November 201327 November 2013The Home SecretaryNone‡Accidental death from ingestion of alpha-methyltryptamine (AMT)Recreational use
19 and 20M, M30 November 201428 April 201515 May 2015The Home Secretary7 July 2015
(53 days)		Accidental death from ingestion of ecstasyRecreational use
NSMNS8 January 201413 January 2014The Home Secretary19 March 2014
(65 days)		Accidental death from ingestion of a synthetic opioid, AH-7921 (3,4-dichloro-N-{(1-(dimethylamino)-cyclohexyl)methyl}benzamide)Recreational use

  • *Recipients of such reports have 56 days from the date of report to respond to the coroner under Regulation 29 of The Coroners (Investigations) Regulations 2013.

  • †The verdicts have been interpreted from the prevent future death reports and are not the verbatim verdicts in the coroners’ reports on the inquests.

  • ‡In cases marked ‘none’, replies were still apparently overdue on 3 May 2021; however, not all replies are posted on the judiciary website.

  • F, female; M, male; NS, not stated; OTC, over the counter.