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

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.