A series of safeguarding gaps in an online pharmacy’s “tick-box” questionnaire model led to a Suffolk woman accessing fatal quantities of prescription medicine, an inquest into her suicide has found. 

Kim Robinson, who suffered from “chronic and debilitating” back and leg pain and was prescribed medication for this by her local GP, was found dead in her Suffolk home on the morning of May 12, 2024, wrote senior coroner Nigel Parsley in a prevention of future deaths report published last Friday (January 31).

Toxicological analysis revealed that an anxiety, heart and blood pressure medicine was in her system at “significantly above the toxic level”.

The drug had not been prescribed by her usual GP, but by an online pharmacy using a “tick-box exercise” that Kim – who had previously overdosed on prescribed medication – was able to use to obtain the drugs used in her suicide by entering “the required details, rather than her correct details”.

This was in contrast to the way she received her GP-prescribed medication, which was “secured by a loved one” who controlled the amount Kim could access at any one time.

The inquiry heard that when the online prescriber issued the prescription last May 6, they did not have access to Kim’s GP records, and that they would not have signed off on the prescription if this had been the case.

The package was addressed to Kim and gave her “direct access to a fatal quantity of prescription medication,” said Mr Parsley who added: “Had the online prescription not been made, Kim’s death would not have occurred.”

A GP who prescribed medicine for Kim made a number of recommendations to the inquest, arguing that there is a need for online prescribers to be able to access patient records – “at least the summary care records” – and that online consultations could include a question as to whether the patient has ever had suicidal thoughts.

He also told the inquest that it might be beneficial to prescribe medicines with a potential for overdose in smaller amounts, possibly limiting the amount dispensed to “weekly or reduced frequencies”.

The GP said that if measures such as these had been in place he would not have prescribed propranolol for Kim.

The coroner said: “In light of the evidence heard in this case I believe the current system of online prescription service needs to be reviewed.”

In draft guidance published by the General Pharmaceutical Council last September and expected to be finalised this month, the GPhC said that where possible online prescribers should have two-way communication channels with the patient and highlighted that there are risks when prescribers make decisions without access to the patient’s records.

A copy of the coroner’s report was sent to health secretary Wes Streeting, who is under a duty to respond by March 28 outlining measures being taken to prevent similar cases in the future.