Warning Issued to Superintendent Over Unsafe Online Dispensing of High-Risk Medicines Without Adequate Safeguards

Date of Decision: June 5, 2025

Registrant's Role: Pharmacist

Allegations:

• Entering into an agreement with an unlicensed prescriber.
• Dispensing high-risk medicines via an online service without adequate risk assessment or clinical oversight.
• Failing to audit the prescribing service or ensure compliance with UK prescribing guidance.
• Endangering patient safety through potential oversupply or inappropriate supply of medicines.

Outcome: Warning issued

GPhC Standards Breached:

• Standard 1 – Pharmacy professionals must provide person-centred care
• Standard 5 – Pharmacy professionals must use their professional judgement
• Standard 9 – Demonstrate leadership

Case Summary

Allegations

This case involves serious concerns regarding the safety and governance of an online pharmacy service overseen by the registrant, who was acting as the Superintendent Pharmacist at Halliwell Midnight Pharmacy in Bolton. Between approximately January 2018 and October 2019, the registrant entered into an agreement with a prescriber who did not possess a valid license to practice with a UK regulatory authority. This prescriber operated through an online platform, www.prescriptiondoctor.com.

During this time, the registrant facilitated the dispensing of high-risk medicines such as opioids and modafinil without conducting essential checks or safeguards. These medicines are recognized for their potential for misuse, overuse, and abuse, and require robust controls when being supplied, particularly through non-traditional channels like online services. Despite the nature of these substances, the registrant did not conduct risk assessments, perform audits, or verify whether prescribing was based on sound clinical judgement.

Findings

The General Pharmaceutical Council’s Investigating Committee found that the registrant had demonstrated a pattern of neglect in fulfilling key professional obligations. Specifically, he failed to:

• Assess or audit the prescribing service for clinical appropriateness or safety.
• Ensure that the prescriber adhered to UK prescribing standards.
• Review or validate the questionnaire-based consultations upon which prescriptions were based.
• Check whether the patients’ general practitioners were contacted before issuing prescriptions.

These failures exposed patients to the risk of receiving medicines that may have been clinically inappropriate or unnecessarily duplicated, placing their safety at considerable risk. The GPhC highlighted that inspectors found tangible instances of such oversupply.

The Committee stated:

“This put patients at real risk of harm from these medicines.”

GPhC Determination on Impairment

In deciding on impairment, the Committee did not conclude that the registrant’s fitness to practise was currently impaired to a degree that warranted removal from the register or more severe sanctions. However, it considered the conduct to be serious and meriting formal regulatory censure. The actions were found to have breached several critical professional standards related to patient care, judgement, and leadership. While there was no indication of malicious intent, the absence of proactive risk management indicated a concerning disregard for safe practice principles.

Sanction

Given the facts, the GPhC Investigating Committee issued a formal warning, citing the need to mark the seriousness of the case and communicate professional expectations to both the registrant and the wider pharmacy community. The warning will remain on the public register for 12 months.

The GPhC emphasized that any repeat of similar conduct would attract more severe regulatory consequences. The registrant was admonished for placing patient safety at risk by allowing the supply of high-risk medicines without verifying the integrity and safety of the service.

“Prescribing and/or dispensing in an online environment that relies solely on a patient questionnaire with little to no safeguards in place, puts patients at risk, undermines public confidence in the pharmacy and is a serious breach of the Standards for Pharmacy Professionals.”

Key Learning Points for Pharmacy Professionals

1. Due Diligence in Online Services: Pharmacists must ensure that any collaboration with online prescribing platforms includes verification of the prescriber’s credentials and compliance with UK clinical standards. The digital nature of such services does not negate the need for robust clinical governance.
2. Handling High-Risk Medicines: Medicines such as opioids and modafinil demand strict oversight. Risk assessments must be in place, especially in non-face-to-face models. Oversupply can result in significant harm and professional accountability remains with the pharmacist.
3. Auditing and Supervision: Pharmacy professionals are expected to regularly audit services they supervise to ensure that they remain safe, effective, and compliant. Passive oversight is insufficient.
4. Leadership and Accountability: As a Superintendent Pharmacist, the registrant bore ultimate responsibility for service safety. Pharmacy leaders must exemplify best practices and ensure all services under their purview are ethically and clinically sound.
5. Patient-Centred Care Requires Vigilance: Even when operating within commercial or remote service models, pharmacists must uphold the standard of person-centred care. This includes understanding patient context, ensuring safe prescribing practices, and avoiding automated systems that bypass clinical judgement.

This case underscores the importance of maintaining rigorous standards in emerging pharmacy service models, particularly those involving online interactions and the supply of high-risk medications. Pharmacy professionals must balance innovation with an unwavering commitment to patient safety and professional integrity.

Original Case Document

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