Warning Issued for Inappropriate Prescribing of Propranolol via Online Platform Leading to Patient Death

Date of Decision: June 5, 2025

Registrant's Role: Pharmacist

Allegations:

Inappropriate prescribing of a high-risk medication (propranolol) without access to Summary Care Record or independent verification
Failure to consider patient's mental health history
Prescribing based solely on an online questionnaire
Prescribing decision contributed to a patient's fatal overdose

Outcome: Warning issued

GPhC Standards Breached:

Standard 1 – Pharmacy professionals must provide person-centred care
Standard 2 – Pharmacy professionals must work in partnership with others
Standard 3 – Pharmacy professionals must communicate effectively
Standard 5 – Pharmacy professionals must use their professional judgement

Case Summary

Allegations

This case centers on an incident involving the registrant, a Pharmacist Independent Prescriber employed by the Independent Pharmacy, a digital health platform supplying prescription-only medications. The pharmacy dispenses a range of medications, including high-risk drugs such as propranolol, and operates under strict clinical protocols requiring Summary Care Record (SCR) checks for certain prescriptions, particularly for higher-risk medications.

On 11 July 2021, the registrant approved a prescription for 84 tablets of propranolol 40mg for Patient A, who had requested treatment for migraines via an online questionnaire. Although the patient had previously obtained migraine treatment from the pharmacy and had provided additional responses to another prescriber, the registrant did not access the patient’s SCR nor contact the patient’s GP. The prescription was dispensed on 12 July 2021.

Critically, the registrant made the prescribing decision without confirming the patient’s full clinical history. Unbeknownst to him, Patient A had a history of poor mental health and previous overdose attempts. Tragically, after receiving the medication, Patient A took an overdose and died.

Findings

The General Pharmaceutical Council’s Investigating Committee found that the registrant relied too heavily on self-reported information from the patient and failed to carry out a robust clinical assessment, especially critical when prescribing a medication like propranolol, which poses a risk in overdose situations. The registrant acknowledged that he did not follow the established protocol requiring SCR checks for high-risk medications.

The Committee found the following shortcomings in the registrant’s actions:

Lack of independent verification of the patient’s medical history.
Failure to obtain essential clinical information, particularly concerning the patient’s mental health.
Decision to prescribe based on insufficient data, potentially due to the weekend unavailability of the SCR.

While this incident appeared isolated and the registrant typically adhered to SCR-check procedures, the Committee emphasized that the risks associated with online prescribing require heightened vigilance and professional judgment.

GPhC Determination on Impairment

The GPhC did not pursue a fitness to practise impairment finding in this instance. Instead, they determined that a formal warning was appropriate, given the registrant’s acknowledgment of error, insight into the incident, and the steps taken by the Independent Pharmacy to mitigate future risk.

The Committee recognized that the registrant accepted responsibility for his actions, demonstrated reflection and insight, and made commitments to uphold patient safety in future practice. However, they underscored that high-risk prescribing, especially without complete information, is a significant lapse in professional judgment and poses serious risks to public safety.

“Prescribing decisions based predominantly on an online questionnaire for medications deemed high risk… must not be made unless he has assured himself that he has all the necessary information required to prescribe medicines that are both safe and appropriate for the patient.”

Sanction

The Investigating Committee issued a formal warning to the registrant. This warning highlights the seriousness of his conduct and serves as a public declaration of the standards expected of pharmacy professionals. The warning will remain on the public register for 12 months.

The Committee opted for a warning, taking into account the registrant’s otherwise unblemished record, the steps taken to rectify the process at the pharmacy level, and the absence of malicious intent. Nevertheless, they cautioned that similar conduct in the future could attract a more severe response.

Key Learning Points for Pharmacy Professionals

Rigorous Clinical Verification is Essential: Especially in digital and remote prescribing settings, reliance on self-reported information without accessing SCR or confirming with GPs is insufficient when prescribing high-risk medications.
Mental Health Considerations Must Be Prioritized: Pharmacists must be alert to indicators of mental health vulnerability, particularly when prescribing medications that may be used in overdose.
Systemic Safeguards are Vital: Online and remote services must implement robust systems, such as flagging and mandatory checks, to mitigate the risks associated with remote prescribing.
Adherence to Protocols: Deviation from established protocols, even under seemingly justifiable circumstances like weekend constraints, can lead to serious consequences.
Reflective Practice Matters: The registrant’s acceptance of fault and demonstration of insight were significant mitigating factors. Reflective practice and professional development are key components in maintaining public trust and professional standards.

This case serves as a somber reminder of the potential consequences of seemingly minor procedural deviations and reinforces the imperative for pharmacy professionals to exercise diligent clinical judgment at all times.

Original Case Document

The full determination transcript is available to logged in users.