Warning Issued for Online Prescribing Without Adequate Safeguards: GPhC Case on Prescribing Amitriptyline to Vulnerable Patients

Date of Decision: June 26, 2025

Registrant's Role: Pharmacist

Allegations:

  • Prescribing amitriptyline to vulnerable patients without verifying the information provided.
  • Failing to consult with patients' GPs or obtain independent confirmation of diagnoses or medical history.
  • Inadequate risk assessment and safeguarding of vulnerable patients.
  • Over-reliance on online questionnaires in prescribing decisions.

Outcome: Warning issued, published on the register for 12 months

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
  • Standard 8 – Pharmacy professionals must speak up when they have concerns or when things go wrong
  • Standard 9 – Pharmacy professionals must demonstrate leadership

Case Summary

Allegations

This case involves a pharmacist independent prescriber (PIP) working at E-Surgery and E-Pharmacy, a distance-selling model that facilitates online consultations through patient-completed questionnaires. The registrant, serving as a Lead Pharmacist Prescriber, was responsible for evaluating responses and issuing prescriptions accordingly.

Two incidents involving the prescribing of amitriptyline—an antidepressant with known sedative properties and risks of overdose—triggered concern. Patient A was prescribed amitriptyline on 16 June 2020, and Patient B on 12 June 2021. Both patients were deemed particularly vulnerable and were already under close supervision by their general practitioners due to the risks of overdose and self-harm.

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2 thoughts on “Warning Issued for Online Prescribing Without Adequate Safeguards: GPhC Case on Prescribing Amitriptyline to Vulnerable Patients”

    1. Good question – the determination doesn’t specify what training she did. Since the FtP case was due to her lack of following UK prescribing guidelines, perhaps her CPD included reading up on appropriate prescribing of amitriptyline such as NICE pathways or some other prescriber education on pain management.

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