Fitness to Practise Case: Allegations of Inadequate Risk Management in an Online Pharmacy Setting

The GPhC Fitness to Practise Committee reviewed the case of three pharmacists, referred to here as “the registrants,” who faced allegations of misconduct in the management of an online pharmacy. This case highlighted failings in risk management, governance, and safeguarding, particularly in dispensing high-risk medications and managing an online prescribing service.

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Allegations and Proven Findings

1. Inadequate Governance Systems:
   • The pharmacy lacked robust risk management and governance systems to monitor the dispensing of high-risk medications, such as codeine linctus, promethazine, and cyclizine.
2. Improper Dispensing of High-Risk Medicines:
   • Despite policies in place, repeat transactions were identified that indicated misuse.
   • Patient safety was compromised by inadequate monitoring and lack of oversight in sales practices.
3. Failures in Online Prescribing Oversight:
   • Prescriptions were issued through an online service without proper assessments of patient health conditions.
   • Patients could select medications and quantities before consultations, undermining clinical judgment.
4. International Prescriptions Without Risk Assessments:
   • The pharmacy dispensed prescriptions for GenderGP, an international service, without ensuring compliance with UK guidelines.
   • No safeguarding assessments were conducted for vulnerable patients, including minors.
5. Lack of Safeguarding Policies:
   • Safeguarding policies were insufficient to protect children and vulnerable adults from harm.

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Fitness to Practise Findings

The Committee determined that the registrants’ actions:

• Demonstrated serious governance failings, particularly in high-risk and emerging areas like online pharmacy services.
• Compromised patient safety, especially for vulnerable populations.
• Breached professional standards, failing to meet the public’s expectations of integrity and accountability.

While the registrants acknowledged some failings and took steps to improve governance, the Committee found their actions fell significantly short of GPhC standards. Fitness to practise was deemed impaired due to the seriousness of the allegations and their potential to undermine public confidence in the profession.

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Outcome and Sanctions

The GPhC imposed Conditions of Practice for 12 months on all three registrants. These conditions require them to:

• Undergo targeted training in governance and risk management.
• Submit quarterly progress reports to the GPhC.
• Practice under supervision in roles that allow monitoring of compliance with the conditions.

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Key Learning Points for Pharmacy Professionals

1. Risk Management is Critical: Pharmacies must implement robust systems to manage and monitor the dispensing of high-risk medications.
2. Safeguarding Vulnerable Patients: Clear policies must be in place to protect children and vulnerable adults, particularly in online and distance services.
3. Accountability for Online Prescribing: Pharmacists must ensure online prescribers follow UK guidelines and conduct appropriate risk assessments.
4. Governance in New Models: Emerging pharmacy models, such as online services, require enhanced oversight and adherence to professional standards.