Kimberley Liu: Prevention of future deaths report

Alcohol, drug and medication related deaths

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Date of report: 21/12/2023

Ref: 2023-0544

Deceased name: Kimberley Liu

Coroner name: Ian Potter

Coroner Area: Inner North London

Category: Alcohol, drugs medication related deaths

This report is being sent to: Department for Culture, Media and Sport

The Rt. Hon. Lucy Frazer KC MP Secretary of State for Digital, Culture, Media and Sport
Department of Digital, Culture, Media and Sport 100 Parliament Street London SW1A 2BQ
I am Ian Potter, assistant coroner, for the coroner area of Inner North London.
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.
On 17 February 2023, an investigation was commenced into the death of KIMBERLY ANNA LIU, then aged 40 years. The investigation concluded at the end of an inquest, heard by me, on 14 December 2023.  

The conclusion of the inquest was drug-related death, the medical cause of death being:  
1a mixed drug toxicity.
Dr Kimberly Anna Liu had become addicted to sleeping to sleeping tablets, painkilling medication, and other medications with a sedative effect in the years prior to her death.  

On 7 February 2023, Kimberly Liu was found unresponsive at home by her husband and an ambulance was called. Paramedics verified her death at home.  

Post-mortem toxicological analysis revealed numerous prescription-only medications in Dr Liu’s blood at the time of her death. Some of these medications had been prescribed by Dr Liu’s general practitioner and were at or about therapeutic levels; whereas other medications ([REDACTED]), which had not been prescribed by her GP, were found at levels suggestive of excessive use.
(For the avoidance of doubt and any confusion, Dr Kimberly Liu was not a medical doctor).
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
The evidence revealed that from at least 2019, Kimberly Liu had regularly accessed websites specifically aimed at selling prescription-only medications (predominantly medications with a sedative effect) that allowed repeat orders on the same day and did not require a prescription. Those websites included the following:
Despite the different URLs some of the websites appear to be operated by the same company and/or individual(s), in that ordering using an identical WhatsApp number ([REDACTED]) was also permitted.
Correspondence from the websites, following an order being placed, included messaging that suggested that the operator(s) knew that their supply of such medication was likely to arouse regulatory suspicion. By way of example, messaging received in emails following the placing of an order, included the following:
‘This is to inform you that usage of the name “Sleeping Tablets” during the payment at the banks is prohibited. Kindly do not use the brand name as it can be harmful for us.’
On one occasion in December 2021, the same website [REDACTED]
 permitted identical orders of [REDACTED] tablets within nine minutes of each other, without question or checks. Three days later a further order of
was again permitted without any query.
The concern here is that these websites, and potentially other similar websites, are not only operating without regulation, but that they appear to exploit already vulnerable individuals by facilitating an almost unseen feeding of dangerous medication addictions thereby placing those individuals in grave danger.
Although the inquest I heard did not concern a death by suicide, the additional concern is that these websites could also be seen to equip people with the means to complete suicide.
I believe that consideration ought to be given to the impact that the availability of such websites has on the population at large, together with the significantly increased risks to those who have developed an addiction to such medications or may even be contemplating acts of self-harm. I also believe that consideration ought to be given to whether and what action(s) could be taken to remove or limit access to or the availability of such websites.
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 February 2024. 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Person:
[REDACTED] (husband of Dr Kimberly Liu).
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he 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.
9Ian Potter
HM Assistant Coroner, Inner North London