Christopher Brazil: Prevention of Future Deaths Report
Alcohol, drug and medication related deathsWales prevention of future deaths reports (2019 onwards)
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Date of report: 23/04/2025
Ref: 2025-0198
Deceased name: Christopher Brazil
Coroners name: Louisa Corcoran
Coroners Area: Ceredigion
Category: Alcohol, drug and medication related deaths | Wales prevention of future deaths reports (2019 onwards)
This report is being sent to: Department of Health and Social Care | Department for Digital, Culture, Media and Sport
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care and the Secretary of State for Digital, Culture, Media and Sport | |
| 1 | CORONER I am Louisa Corcoran, Assistant Coroner for Ceredigion |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 8 August 2022, an investigation into the death of Christopher Brazil aged 45 was commenced, which I concluded on 15 April 2025. The conclusion of the inquest was that Mr Brazil unintentionally overdosed on benzodiazepines, which he was taking regularly and died a drugs related death. |
| 4 | CIRCUMSTANCES OF THE DEATH Mr Brazil had suffered from an accident some time before his death in which he sustained injuries that left him with pain; he also suffered with sciatica and he became depressed during the pandemic. Mr Brazil accessed his GP and was prescribed some medication for his ailments but, in a bid to self-medicate in order to manage his pain and, at times, poor mental health, Mr Brazil also sourced additional medicines and drugs. He was able to buy from illegal websites, which depicted themselves as safe, regulated, online pharmacies. Mr Brazil died after inadvertently overdosing on benzodiazepines. They were not prescribed by his doctor or the NHS. Investigations by the police and the Medicines and Healthcare Products Regulatory Agency (MHRA) have found that these were bought by Mr Brazil from unlawful providers operating under these websites: [REDACTED] and [REDACTED]. Mr Brazil was able to buy prescription drugs from illicit providers on a regular basis; there are two A and E records in February and April 2022 of Mr Brazil being intoxicated on benzodiazepines, before he subsequently died from benzodiazepine toxicity in August 2022. 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. On the last order made, the drugs were delivered the next day via Royal Mail. Evidence shows that Mr Brazil was not suicidal, but he was anxious to manage pain and was not directed by a healthcare professional as to how much to take and when. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6) (2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications (3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs (4) There is a lack of guidance regarding dosage (5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers (6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs (7) 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. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 June 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to Mr Brazil’s family. I have also sent a copy of this report to Mr Brazil’s G.P., the MHRA and the police. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | 23 April 2025 Louisa Corcoran, Assistant Coroner for Ceredigion |