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A 45-year-old man who suffered from chronic pain died after taking an unintentional overdose of benzodiazepines bought from "unlawful providers" posing as "legitimate" and regulated online pharmacies, an inquest has found.

Christopher Brazil of Ceredigion died from benzodiazepine toxicity in August 2022. In a recent report to prevent future deaths, assistant coroner Louisa Corcoran said the evidence showed he was "not suicidal" but was "anxious to manage pain" and had not been counseled by a healthcare professional on using the drugs safely. 

Mr Brazil suffered from pain following an accident, in addition to sciatica and depression that began during the pandemic. 

He was prescribed medicine by his GP but also turned to "illegal websites" that "depicted themselves as safe, regulated online pharmacies," the assistant coroner reported. 

He was able to buy prescription drugs from these websites "on a regular basis" and twice in the months leading up to his death presented at A&E "intoxicated on benzodiazepines".

"Mr Brazil was struggling with physical pain and mental health issues and was susceptible to using this unlawful method, which was quick and readily available," said Ms Corcoran.

She found that the final order placed by Mr Brazil was delivered to his home address the next day via Royal Mail. A subsequent investigation by the MHRA found that the sites he had used were operating illegally.

The assistant coroner's report warned that "vulnerable and susceptible" people can readily access prescription medicines and controlled drugs from "unregulated and unlawful websites" that are "found easily from simple online searches".

Among the numerous safety issues she identified with these sites were: the fact that there are "insufficient or no measures" to verify a patient's medical history before making a sale; the lack of guidance on safe dosage; and a lack of age and identity verification which means minors could access harmful drugs.

She added: "The fact that it is possible for unlawful and unethical online pharmaceutical providers to  operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources."

Her report was copied to health secretary Wes Streeting, who is obliged to respond by June 18 explaining what action his department will take or explaining why no further action is required.

While the General Pharmaceutical Council has taken numerous steps to clamp down on unsafe prescribing by registered online pharmacies, websites such as the ones used by Mr Brazil operate outside the law and are subject to MHRA enforcement. 

In January, the MHRA said it seized black market medicines with a total street value of £40m in 2024, one-third higher than the year before.