Pharmacist Suspended for Unsafe Online Prescribing of Opioids and Z-Drugs

Date of Decision: January 20, 2022

Registrant's Role: Pharmacist

Allegations:

• While working as an Independent Prescriber (PIP) at Instant E-Care Ltd, the pharmacist:
• Prescribed excessive quantities of opioids and Z-drugs to patients without adequate clinical checks.
• Did not communicate with patients’ GPs, even when given consent, before prescribing high-risk medications.
• Prescribed outside the scope of practice, issuing medication for chronic pain, hormonal conditions, and mental health disorders despite limited relevant training.
• Allowed patients to pre-select medications and dosages through an online system without conducting meaningful consultations.
• Failed to identify and address red flags in patient histories, issuing multiple prescriptions against current medical guidelines.
• A journalist from The Times obtained 200 dihydrocodeine tablets and an additional 28 tablets within two days, highlighting loopholes in the pharmacy's opioid policy.
• The GPhC investigation found no evidence of safe prescribing processes, and an expert witness deemed the prescribing "excessive" and "potentially dangerous."

Outcome: A 9-month suspension was imposed

GPhC Standards Breached:

• Standard 1 – Provide Person-Centred Care
• Standard 2 – Work in Partnership with Others
• Standard 5 – Use Professional Judgment
• Standard 8 – Speak Up When Things Go Wrong
• Standard 9 – Demonstrate Leadership

Case Summary

Original Case Document