A grandfather died after taking twice the quantity of drugs he was normally prescribed because of "an individual failing" at a chemist, a coroner said.
Richard Lee, 84, from Doncaster, was inadvertently given double his medicine by two separate Boots pharmacies in a "communication breakdown".
Assistant coroner Louise Slater said the overdose was a "contributory factor" in Mr Lee's death.
Boots said patient welfare was "at the heart" of the firm.
Mr Lee collapsed at his Norton home in 15 December 2016 and died holding his daughter's hand, five hours after being admitted to hospital, the court heard.
'Lack of clarity'
Mr Lee took was given two sets of drugs by two different Boots branches in the Doncaster area following a communication mix-up.
Assistant coroner Louise Slater told the inquest at Doncaster Coroner's Court excess dosing would have increased the risk of a cardiac event and was "a contributory factor" in his death.
Mrs Slater said seven of the 13 drugs Mr Lee was taking would have affected his blood pressure or heart rhythm.
Mr Lee's daughter Gail Pickles told the inquest the Boots pharmacy in Askern had agreed to supply his medication via Medisure packs, but it was suddenly unable to process his prescription and handed responsibility to another branch in Frenchgate.
It was later transferred to a third branch, attached to the Askern Medical Practice, where Mr Lee was a patient.
Mrs Slater told the inquest shortfalls in communication had "resulted in a lack of clarity as to which pharmacy would assume responsibility".
"I'm satisfied that policies and procedures were in place at the pharmacies," she said.
"However, they were not followed on this occasion due an individual failing rather than a systemic failure."
Following the inquest Mrs Pickles said: "Still, to this day, no-one from Boots has ever apologised to me for the error or my father's death..."
She said she was "devastated to see that no-one from Boots" had attended the inquest conclusion.
"I have repeatedly, over the past 18 months, written to Boots asking for them to review how they treat families of patients who have been harmed or, like in my case, where there has been a death - I have yet to receive a positive response from them."
A Boots UK spokesman said it had carried out a thorough investigation following Mr Lee's death and had put measures in place "to prevent a similar incident happening again in the future".
A BBC investigation earlier this year uncovered allegations of work pressures on Boots pharmacists staff and company safety procedures not being followed.
But the General Pharmaceutical Council concluded there was "not sufficient evidence overall to suggest a risk to patient safety across the organisation".
- 25 June 2018
- 8 January 2018