Paul Pidgeon: Prevention of future deaths report

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Chief Executive Officer Booker Group Limited Irthlingborough Road Wellingborough Northants
NN8 1LT

Miss Anna Crawford, H.M. Assistant Coroner for Surrey

I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009.

An inquest into the death of Paul Pidgeon was opened on 7 June 2022.  It was resumed on 4 July 2025 and concluded on 14 July 2025

The medical cause of Mr Pidgeon’s death was:
1a. Paracetamol Toxicity
2. Coronary Artery Disease, Hepatic Steatosis

The inquest concluded with the following Narrative Conclusion:
On 20 March 2022 Mr Pidgeon was found deceased at his home address. On 19 March 2022 he had deliberately overdosed on paracetamol. It has not been possible to establish his intentions in doing so.  His death was caused by Paracetamol Toxicity and contributed to by his pre-existing conditions of Coronary Artery Disease and Hepatic Steatosis, which made him more susceptible to succumbing to Paracetamol Toxicity.

The circumstances of Mr Pidgeon’s death are set out above.
In addition, to the matters set out above, the court heard evidence that:
On 20 March 2022, when Mr Pidgeon was found deceased, there
were approximately [REDACTED] empty packs of Galpharm Ibuprofen and [REDACTED]  empty packs of Galpharm Paracetamol next to him.
Mr Pidgeon was a mechanic and owned Southfields Garage in Wimbledon and had a business account with Booker Wimbledon, a
wholesaler.

On 19 February 2022, the Southfields Garage trade account was
used to purchase [REDACTED] of Galpharm ibuprofen and [REDACTED]
of Galpharm paracetamol at Booker, Wimbledon.

On 5 March 2022 the Southfields Garage trade account was used to
purchase a further [REDACTED] of Galpharm paracetamol at Booker, Wimbledon.

The MATTER OF CONCERN is:
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.   [REDACTED]

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.

In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action.

You are under a duty to respond to this report within 56 days of its date; I may extend that period on request.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must explain why no action is proposed.

I have sent a copy of this report to the following:
1.   Chief Coroner
2.   Mr Pidgeon’s family
3.   Medicines and Healthcare Products Regulatory Agency