A coroner has reported on the tragic case of a young man with a history of suicidal ideation who took his own life after acquiring 112 excess tablets in the process of changing his nominated pharmacy from Pharmacy2U to a local brick-and-mortar pharmacy. 

Oliver James Billings, a 22-year-old man with a history of mental health issues, was found dead in his home on December 6, 2023. He had consumed “possibly as many as 266 x 75mg tablets” of his prescribed medication, wrote Luisa Nicholson, assistant coroner for Devon, Plymouth and Torbay. The name of the medicine is redacted from her report. 

The coroner expressed her concern that after changing his nominated pharmacy from Pharmacy2U to a local Superdrug branch, he ended up receiving both prescriptions “and was suddenly in possession of 224 tablets”.

GP practice Clare House Surgery in Tiverton sent an electronic request to Pharmacy2U to cancel his prescription and then issued a new one to the Superdrug store, but the distance dispenser “had already ‘pulled down’ the prescription before it was cancelled electronically”.

This meant that he received both the 112 tablets dispensed by Pharmacy2U, which were posted to him on November 28 last year, and the new prescription for 112 tablets from Superdrug. 

The surgery had sent Oliver a text message asking him to direct Pharmacy2U to “return the prescription to the spine” which “presumably he chose to ignore,” wrote Ms Nicholson, adding that he had apparently “hoarded some of his medication”.

Commenting on Oliver’s history of mental health problems, she wrote: “He had a long-established history of issues with his mental health including anxiety, depression, self-harm and previous suicidal ideation.

“He was also aware of his own impulsiveness. A note was found by a police officer attending Oliver’s flat on the day he died which stated that he did not have control over his medication and would take them all if left unsupervised.

“This is sadly what appears to have happened.”

The coroner brought up three areas of concern arising from the events that culminated in Oliver’s suicide. Firstly, that a new prescription was issued “in the knowledge that the first was cancelled or to be cancelled” without steps being taken beforehand to ascertain the status of the original prescription.

Secondly, she said that while the “swift dispatch of medication” is “necessary in many circumstances,” it does not “allow for mistakes to be noticed and/or remedied”. 

And she noted that “the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted”. 

Copies of the report were sent to Clare House Surgery, Pharmacy2U and the Royal Pharmaceutical Society, all of whom must respond by January 24, 2025 with details of actions they have taken or plan to take to present similar events in the future – or an explanation as to why no action is required. 

Pharmacy2U and Clare House Surgery have been approached for comment.