Paul Pidgeon

Miss Anna Crawford  
H.M. Assistant Coroner for Surrey  
By Email Only  

29th October 2025 

Dear Assistant Coroner, 

Regulation 28 Report Response on behalf of Booker Group Limited ("Booker") 

1.  Introduction  

1.1.  We refer to your Regulation 28 Report dated 11 August 2025, and thank you for the opportunity 

to provide a response on behalf of Booker in relation to your concerns, namely that:  

1. 

The Guidelines for the Good Distribution Practice of Medicinal Products for Human Use 

(2013) state that wholesale suppliers must ensure that they supply medicinal products 

only  to  those  who  are  themselves  in  possession  of  a  wholesale  distribution 

authorisation  or  who  are  authorised  or  entitled  to  supply  medicinal  products  to  the 

public.  The Guidelines go on to set out measures by which wholesalers can comply 

with that duty, including by requesting and checking a customer’s status.  

2. 

Mr Pidgeon was a mechanic and his business account with Booker was in relation to 

his garage business.  His business did not involve the onward supply of medication to 

the public.  However, he was able to bulk purchase both paracetamol and ibuprofen 

from Booker in Wimbledon on two occasions. It does not appear that any checks were 

carried out to confirm his status prior to the sales.  

3. 

The  Coroner  is  therefore  concerned  that  Booker  in  Wimbledon,  and  therefore 

potentially Booker more widely, may be selling medicinal products to customers who 

are not authorised or entitled to supply them to the public.  Given, the potential for this 

to  result  in  significant  amounts  of  medicines  being  sold  in  single  transactions,  the 

Coroner is concerned that this gives rise to the risk of future deaths. 

1.2.  We understand that the Inquest was opened on 7 June 2022 and concluded on 14 July 2025. 

However,  Booker  was  not  aware  that  the  Inquest  was  taking  place,  nor  was  it  aware  of  the 

tragic circumstances of Mr Pidgeon's death on 20 March 2022 until it received the Regulation 

28 Report on 11 August 2025, almost three and a half years later. As such, Booker would like 

to take this opportunity to offer its sincere condolences to the friends and family of Mr Pidgeon. 

It  is  unfortunate  that  Booker  was  not  invited  to  make  representations  at  the  Inquest  as  an 

Interested Person. This would have provided it with a much earlier chance to present the below 

information which we hope will address the Assistant Coroner's concerns. 

1.3. 

At the material time, Booker had systems in place that implemented the Guidelines for the Good 

Distribution  of  Medicinal  Products  for  Human  Use  ("the  GDP").  These  systems  included 

processes that all customers were validated to determine if they were buying products for their 

business or enterprise and not for personal use.  In addition to this, as will be described below, 

Booker stored medicinal products in a room that could only be accessed on request to further 

Equity House, Irthlingborough Road, Wellingborough, Northants NN8 1LT   
T: +44 (0)1933 371000  F: +44 (0)1933 371396 

Booker is the trading name of Booker Limited. Booker is a member of Tesco plc. Registered in England No. 197380 Equity House, 
Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT. VAT Reg. No. GB 220 4302 31 

 
 
 
 
 
 
 
 
 
 
  
 ensure that only the correct customers could access the products. The Wimbledon branch used 

the same system.   

1.4. 

Given that a significant period of time has passed since Mr Pidgeon made his purchases at the 

Booker Wimbledon Branch, Booker has changed various aspects of its systems and where the 

system in place today materially differs from that in place in 2022, we have made this clear in 

our  response.  These  changes  have  been  made  as  a  result  of  ongoing  development  and 

improvement in Booker's processes and procedures, and further training and insights obtained 

through the appointment of an external consultant advisor in this area. 

1.5. 

Booker  is  confident  that  its  current  systems  would  prevent  the  sale  of  medicines  to  any 

customers who are not authorised or entitled to supply medicines to the public themselves. We 

will discuss each of the following features of our system in detail in the rest of this response, as 

well as our wider Quality Management System in relation to the sale of medicines, but the key 

aspects which we hope will allay the Coroner's concerns are the following: 

a)  Booker has a stringent qualification process in place for customers which requires them to 

prove they are entitled to supply the public (retail).. In order to qualify, customers must bring 

documented  evidence  of  their  business  type  into  store  following  an  online  registration 

process, which will be checked by branch staff before they are registered as qualifying on 

the system.  

b)  A  till  block  was  introduced  in  September  2025  so  that  any  customers  trying  to  buy 

medicines when they are not validated to do so will automatically be blocked from making 

the purchase. There is no option for branch staff to overwrite the till block.  This will prevent 

anyone  who  isn’t  categorised  on  the  Booker  system  as  a  retailer,  school  nurse  or  care 

home will not be able to purchase medicines.  

c)  Any customers who are visiting the restricted medicines area of the branch are required to 

sign a medicine customer declaration form to confirm they are appropriately registered to 

purchase medicines before leaving the store. 

d)  Booker's branch manual has been updated with the requirement for branch staff to recheck 

the validity of customers registered to buy medicines every 2 years, starting from January 

2026. This process would include any historical accounts as well as any new registrations 

going forward.  

2.  Quality Management System ("QMS") 

2.1. 

Booker has in place a QMS for the sale of medicines in its branches to customers. This system 

allows it to operate in line with the licenses it holds granted by the MHRA and the requirements 

of the GDP. The QMS is applicable across all MHRA licensed branches of Booker and is not 

specific to the Wimbledon Branch where Mr Pidgeon made his purchases in 2022.  

2.2. 

Booker has a designated full time MHRA approved Responsible Person ("RP") and also an RP 

who has been working with Booker under a contract as a consultant for the last two years to 

review and develop the QMS. The full time RP is responsible for implementing Booker's QMS 

in a manner that enables Booker to demonstrate its GDP compliance and that its public service 

obligations are met.  

Equity House, Irthlingborough Road, Wellingborough, Northants NN8 1LT   
T: +44 (0)1933 371000  F: +44 (0)1933 371396 

Booker is the trading name of Booker Limited. Booker is a member of Tesco plc. Registered in England No. 197380 Equity House, 
Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT. VAT Reg. No. GB 220 4302 31 

 
 
 2.3. 

Booker has improved its reporting lines for staff to cascade issues to the RP. Booker has an 

internal Medicines Group made up of representatives from all areas of the business that have 

a role in the wholesaling of medicines. This includes Quality Assurance, Supply Chain, Buying, 

Health and Safety, legal, our RP, and our Operations Team. Having a centralised governance 

team like this gives our RP a way to receive information from the business and also to cascade 

information down to every level, including to our branch teams and to continually evolve the 

QMS.. 

The QMS incorporates all of the controls listed in the rest of this response below.  

3.  Branch Manual  

3.1. 

Booker has a Branch Manual in place for Medicine Controls which is held in paper copy in each 

of its branches as well as being available to colleagues online via our colleague communication 

system. Version 17 of the Branch Manual was in place at the time of Mr Pidgeon's purchases 

in 2022, and the current version (version 20) was issued on 15 August 2025.  

3.2. 

The purpose of the Branch Manual is to provide a quick reference guide for all store colleagues 

and  managers  as  to  the  required  processes  for  achieving  compliance  with  both  the  MHRA 

licence conditions and GDP. The customer qualification process, set out below, is incorporated 

in the Branch Manual and defines the requirements of GDP, including that Booker will only sell 

medicines  to  persons  or  organisations  who  are  authorised  or  entitled  to  supply  medicinal 

products to the public.  

3.3. 

All  Area  and  Branch  Managers,  and  any  colleagues  handling  medicines  are  trained  on  the 

contents  of  the  Branch  Manual.  In  the  current  version  of  the  Branch  Manual,  all  relevant 

colleagues sign the back sheet to confirm that they have read and understood the procedures 

and will follow the instructions within the Branch Manual.  

4.  Pre-Purchase Controls: Customer Qualification  

4.1. 

As  the  Assistant  Coroner  is  aware,  Booker  is  a  wholesale  retailer  and  sells  goods  to  other 

businesses  for  use  in  or  re-sale  by  the  customer’s  business  and  is  not  open  to  the  general 

public. In order to shop at any Booker branch, customers need a trade card membership. To 

qualify  for a card, customers need to be in  business,  self-employed,  a registered charity, or 

some form of organisation such as a local club (scouts, sports clubs, PTAs).  

4.2. 

Customers must be able to evidence their business or entity when they first register for a trade 

card, so that we can be certain their purchases are for that trade use. This will involve them 

firstly completing an online form and then attending their local branch to present the paperwork 

to  demonstrate  what  their  business  is.  This  will  entitle  the  customer  to  obtain  a  customer 

registration card. Booker’s terms and conditions of registration specify that purchases must only 

be made for their business use.  

4.3.  Medicinal  products  may  only  be  purchased  by  registered  Booker  trade  customers  who 

themselves sell the product to consumers or alternatively are able to supply the products within 

their business (such as care homes or schools). Under MHRA regulations, Booker  must not 

sell any medicinal  products to customers  who do not fall  into these categories,  or to branch 

colleagues.  

Equity House, Irthlingborough Road, Wellingborough, Northants NN8 1LT   
T: +44 (0)1933 371000  F: +44 (0)1933 371396 

Booker is the trading name of Booker Limited. Booker is a member of Tesco plc. Registered in England No. 197380 Equity House, 
Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT. VAT Reg. No. GB 220 4302 31 

 
 
 4.4. 

In order to purchase medicines from a Booker branch, Booker's medicine customer qualification 

process  requires  customers  to  be  qualified  and  verified  specifically  for  the  purchasing  of 

medicines prior to being able to do this/ or to continue to do this. This is over and above the 

process  customers  need  to  undergo  to  obtain  a  trade  card.  Booker's  current  system  for 

customers qualifying to purchase medicines in its branches has been in place since April 2025.   

4.5. 

The procedure to qualify for the purchasing of medicines is as follows:  

a) 

A customer will complete an initial registration online to their preferred store. The online 

registration requires the customer to confirm they are a retailer, a school nurse, or a 

nursing home.  

b) 

The customer then comes into the store with  documentary evidence to demonstrate 

this.  

c) 

A trained receptionist/designated branch colleague checks the evidence provided by 

the customer against what was entered online during the initial registration process.  

d) 

The receptionist or designated colleague checks that the business is a UK registered 

retailer with Companies House, for non limited companies letterhead or other formal 

documentation,  such  as  a  letter  from  HMRC  will  be  required.      For  certain  types  of 

businesses, other specific checks are undertaken including:  

•  For nursing homes, the receptionist/designated staff check the same nursing 
home ordering the medicines is registered at the Care Quality Commission.   
•  For schools, only a nurse can be supplied. The school nurse must provide their 
UK nursing registration. The receptionist or designated branch colleague must 

verify 

the 

school 

address 

at 

https://get-information-

schools.service.gov.uk/Search  and  any  nurse  registration  with  The  Nursing 
and Midwifery Council.  

•  For  pharmacies,  the  registrations  of  both  the  pharmacy  and  the  pharmacist 
ordering  medicines  must  be  verified  against  the  General  Pharmaceutical 

Council register.  

e) 

Once the receptionist/designated colleague is content all the required information has 

been provided, the Area Manager or Branch Manager must sign off the new customer 

checks. Once that has been completed, the customer will be verified as registered so 

that our systems will permit them to purchase medicines from our branches.  

f) 

Booker's systems are designed to allow us to check the customer type and therefore 

verify  customers  are  permitted  to  purchase  medicines  so  that  we  can  ensure  only 

appropriate people are able to do so, as well as allowing us to maintain the necessary 

records of who has made such purchases.  

g) 

Checks to validate entitlement to purchase medicines are documented and rechecked 

every two years as of January 2026.  

4.6. 

The customer medicine qualification procedure is contained within the most recent version of 

the Branch Manual which is held at every branch in paper copy as well as being available in 

electronic form should colleagues need to consult it at any time.  

Equity House, Irthlingborough Road, Wellingborough, Northants NN8 1LT   
T: +44 (0)1933 371000  F: +44 (0)1933 371396 

Booker is the trading name of Booker Limited. Booker is a member of Tesco plc. Registered in England No. 197380 Equity House, 
Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT. VAT Reg. No. GB 220 4302 31 

 
 
 4.7.  Mr Pidgeon had held an account with Booker for over 20 years at the time of his death.  The 

qualification  system  for  members  would  have  been  different  at  the  point  that  he  joined. 

Unfortunately,  given  the  time  that  has  passed  since  Mr  Pidgeon  underwent  the  onboarding 

process to obtain  his trade card, Booker  is no longer  able to access the  documents that he 

provided at the time to demonstrate he was a business owner or the nature of his business. It 

is possible that there was a miscommunication regarding the type of business he owned during 

the onboarding process at the time he was registered as a customer or over the passage of 

time. This is however speculative.  

4.8. 

As per the above, Booker now has a system which only permits sales to certain categories of 

customer,  those  who  are  themselves  authorised  to  sell  or  supply  general  sales  ledger 

medicines. The system is based a customer classifications and qualification checks which will 

be  re-done    every  two  years  to  avoid  a  scenario  arising  where  someone  maintains  their 

qualification to purchase medicines when they should no longer be able to.  

5.  Additional In-Store Controls 

5.1. 

All Booker sites which sell restricted products such as medicines and tobacco have a lockable, 

designated room in which those products are stored and displayed for sale. At the Wimbledon 

branch, this room is sealed off from the main floor of the branch by a lockable roller  shutter. 

The  roller  shutter  should  remain  closed  unless  a  customer  with  the  adequate  customer 

qualification to enable them to purchase restricted products requests for a trained member of 

staff to open it for them and accompany them in the room while they make their purchases. In 

this  way,  Booker  prevents  not  only  access  by  customers  who  are  not  allowed  to  purchase 

restricted products but removes them from sight to other customers as well.  

5.2. 

There is signage on display with regards to the sale of medicines with the below wording:  

"Unfortunately we are unable to sell bulk quantities of medicinal products to customers 

unless the purpose of the purchase is solely for trade and not personal use. We cannot 

sell medicinal products to Day Pass Holders or Members of Staff." 

There is a footnote to this notice which states:  

"This restriction applies to all paracetamol, ibuprofen, or aspirin based products, cough 

medicines or antiseptic creams"  

5.3. 

In addition to this sales restriction  notice within the restricted  products room,  there is also  a 

sales restriction notice clearly displayed at the medicines sales fixtures which is positioned so 

it can be easily seen and read by all customers.  

5.4. 

The above in-store controls were all in place in 2022 at the time when Mr Pidgeon made his 

purchases. The further customer qualification checks for the sale of medicines will additionally 

strengthen these processes.   

5.5. 

In addition to the above controls, Booker has now implemented a till  block which will appear 

automatically  on  the  screen  at  the  cash  desk  if  the  cashier  scans  through  any  medicinal 

products to a non-qualified customer. This will prevent the purchase being registered on the till, 

meaning  there  is  no  way  for  the  cashier  to  make  the  sale.  There  is  no  option  for  this  to  be 

overridden by any colleagues.  

Equity House, Irthlingborough Road, Wellingborough, Northants NN8 1LT   
T: +44 (0)1933 371000  F: +44 (0)1933 371396 

Booker is the trading name of Booker Limited. Booker is a member of Tesco plc. Registered in England No. 197380 Equity House, 
Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT. VAT Reg. No. GB 220 4302 31 

 
 
 5.6. 

These  steps  will  ensure  that  moving  forward  there  should  be  no  further  confusion  around  a 

customer’s role in the medicine supply chain, as seems to have occurred with Mr Pidgeon and 

whether they are permitted to be supplied medicine products by Booker. 

6.  Training  

6.1. 

All Booker colleagues who are employed at a branch stocking medicinal products must undergo 

medicines  compliance  training.  This  training  is  undertaken  as  part  of  colleagues'  mandatory 

inductions  when  they  first  join  Booker,  and  in  2022,  there  was  a  requirement  for  it  to  be 

refreshed every three years.  

6.2. 

Since April 2025, there has been a requirement for GDP training to be refreshed annually. GDP 

training  has  also  now  been  moved  online  so  that  completion  rates  can  be  more  closely 

monitored. At the end of the training, colleagues must take a competency test and must achieve 

a pass mark of at least 75% in order to pass the training. The training specifically covers the 

requirement  for  medicines  only  to  be  sold  to  customers  who  meet  the  necessary  customer 

qualification, and how that process works. Only colleagues who have passed the training can 

be involved in the sales of medicines in our branches. 

6.3. 

In 2022, Booker's records for the Wimbledon branch show that all colleagues involved in the 

sale of medicines had completed their required training.  

7.  Monitoring and Auditing 

7.1. 

A  vital  part  of  the  QMS  system  is  the  ability  for  the  Company  to  monitor  and  audit  that  its 

systems have been implemented and are working as expected.  

7.2. 

Audits specifically in relation to the sale of medicines are carried out by the RP or Contract RP 

at each of our branches to assess compliance of branches with  the Branch Manual and the 

requirements of GDP. This includes checking that branches are selling medicinal products to 

the right entities. These audits have been an important part of our QMS system. The nature 

and content of these audits has changed as our processes and QMS has evolved. Where our 

audits flag any issues, these must be documented with a Corrective and Preventive Action Plan 

(CAPA Plan) in order to correct deviations, address audit findings and mitigate risks identified. 

7.3. 

Booker also has in place a change control system to ensure that changes to branch processes 

or  any  other  changes  that  potentially  impact  patient  safety  or  regulatory  compliance  are 

identified, monitored and managed effectively. 

7.4. 

Lastly,  we  have  in  place  a  periodic  management  review  of  the  QMS  objectives  by  Senior 

Management, the RP and relevant Area Leads to monitor the effectiveness of the system and 

implementation  of  CAPA  Plans  or  improvements  such  as  improving  robustness  of  the 

qualification process. 

8.  Closing Remarks 

8.1. 

Booker Limited takes compliance with GDP very seriously and has a robust QMS in place to 

manage this.  Booker has undertaken a process of continuous improvement  of its QMS over 

several years, including specific and detailed branch audits by the RPs, a new branch manual 

and an increased frequency of training on GDP and our internal processes for our colleagues.   

Equity House, Irthlingborough Road, Wellingborough, Northants NN8 1LT   
T: +44 (0)1933 371000  F: +44 (0)1933 371396 

Booker is the trading name of Booker Limited. Booker is a member of Tesco plc. Registered in England No. 197380 Equity House, 
Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT. VAT Reg. No. GB 220 4302 31 

 
 
 8.2.  Whilst  we  cannot  fully  explain  specifically  how  Mr  Pidgeon  was  able  to  purchase  medicines 

from Booker Limited, the ultimate root cause was insufficient customer qualification. This has 

now  been  remedied  with  a  tighter  qualification  process  which  requires  each  customer 

qualification to be refreshed every two years. This is supported specifically with a system till 

block  that  prevents  sales  being  made  to  any  customer  that  has  not  demonstrated  that  their 

organisation is involved in the sale or onward supply of medicines.  

8.3.  We trust the above satisfies you that Booker has in place an effective system that complies with 

the GDP to ensure  customers who are not authorised or entitled to supply  medicines to the 

public are not able to purchase them from any Booker branches. Given the changes that Booker 

has already implemented in this area to strengthen its QMS, we hope this demonstrates that 

no further action is required beyond those changes already detailed above.  We regret that we 

did not have the opportunity to provide the above information during the course of the inquest.  

Yours faithfully,  

Booker Group Limited 

Equity House, Irthlingborough Road, Wellingborough, Northants NN8 1LT   
T: +44 (0)1933 371000  F: +44 (0)1933 371396 

Booker is the trading name of Booker Limited. Booker is a member of Tesco plc. Registered in England No. 197380 Equity House, 
Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT. VAT Reg. No. GB 220 4302 31