Warning Issued for Failing to Vet Online Prescribing Service: Lessons on Pharmacist Due Diligence

Date of Decision: October 22, 2025

Registrant's Role: Pharmacist

Allegations:

Dispensing medication for an online prescribing service without ensuring it was properly regulated
Failing to conduct due diligence on the service’s governance, clinical oversight, and patient safety procedures
Not verifying processes related to patient identification, consent, and medical history access
Inadequate risk assessment and auditing of online service dispensing
Dispensing without sufficient information to ensure clinical appropriateness

Outcome: Warning issued and published on the GPhC 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 5 – Pharmacy professionals must use their professional judgement

Case Summary

Allegations

This case centers on the conduct of a pharmacist who, between June 2023 and July 2024, operated as both a director and, on occasion, the Responsible Pharmacist (RP) at a pharmacy dispensing medication for an online prescribing service. The core allegations involved failures in professional judgement, governance, and due diligence relating to this arrangement. Specifically, the registrant failed to ensure that the online prescribing service was properly regulated, had robust clinical oversight, and adhered to safe prescribing practices.

The registrant did not verify whether the online service had established procedures for clinical decision-making, patient monitoring, or safe management of potentially abusable medicines. He also neglected to check how the service gathered and validated patient identity and medical histories, or whether patients had provided consent for information sharing with NHS providers. Furthermore, the pharmacy lacked access to consultation records or patient questionnaires—critical components in assessing the appropriateness of any supply.

These lapses meant that the registrant was often unable to assess the clinical appropriateness of the prescriptions being dispensed or to verify if patients were being adequately monitored. This failure put patients at significant risk, particularly when medicines liable to misuse were involved.

Findings

The GPhC’s Investigating Committee concluded that the registrant’s conduct demonstrated a clear deviation from expected standards of practice. The Committee acknowledged that while the registrant may not have had malicious intent, his failure to perform basic due diligence and governance checks amounted to a serious oversight. They noted that pharmacy professionals, especially those in ownership or RP roles, have a responsibility to ensure the services they work with operate in line with patient safety and professional standards.

The lack of systems for checking patient histories or verifying consent raised particular concerns. Without access to consultation notes or an understanding of how patients were assessed, the registrant could not ensure the appropriateness of any medication being dispensed. This undermined the ability to provide person-centred care and to work in partnership with other healthcare providers, both of which are fundamental principles outlined in the GPhC standards.

GPhC Determination on Impairment

In assessing the issue of impairment, the Committee did not find evidence of current impairment requiring fitness to practise proceedings. However, they determined that a regulatory response was necessary due to the seriousness of the failings and their potential impact on public confidence in the profession.

The GPhC emphasized the importance of professional vigilance, especially when pharmacists choose to collaborate with third-party service providers. A failure to assess the regulatory status and safety protocols of such services reflects a lapse in professional judgement and raises risks of harm to patients.

“To dispense medicines without proper safeguards in place puts public safety at risk and can undermine confidence in the profession.”

They concluded that although no direct harm was evidenced, the potential for harm was significant due to the absence of appropriate checks and the nature of the medicines involved.

Sanction

The GPhC determined that the appropriate regulatory outcome was to issue a formal warning to the registrant. This warning will remain on the public register for 12 months and serves as both a record of the conduct and a caution against future failings.

The Committee stressed that this warning should act as a strong reminder that dispensing medicines for unregulated or poorly governed online services is unacceptable unless robust safeguards are in place. The decision reflected the GPhC’s concern about the increasing prevalence of online prescribing models and the essential role pharmacists play in safeguarding patients.

Additionally, the Committee warned:

“Pharmacy owners must ensure that any services with which they choose to work are appropriately regulated and safe.”

Any recurrence of similar conduct, they noted, would likely trigger further and potentially more serious regulatory intervention.

Key Learning Points for Pharmacy Professionals

Due Diligence Is Non-Negotiable: Pharmacists must conduct thorough assessments of any third-party service they work with, particularly those involved in online prescribing. This includes verifying regulatory oversight, access to clinical records, and patient monitoring protocols.
Responsibility Extends Beyond Dispensing: Merely filling prescriptions is not sufficient—pharmacists have a professional duty to ensure that every supply is clinically appropriate, safe, and made with full knowledge of the patient’s health context.
Patient-Centered Care Requires Information: Without access to consultation notes or patient questionnaires, pharmacists cannot meaningfully assess the appropriateness of therapy. This compromises both safety and standard of care.
Consent and Collaboration Are Critical: Understanding what consent patients have given and ensuring coordination with NHS prescribers are essential parts of professional pharmacy practice. These factors support continuity of care and patient safety.
Regulatory Risk of Online Services: With the rise in online healthcare, pharmacists must be especially cautious. The convenience of digital models does not override the need for safe, regulated, and transparent practices.

This case serves as a powerful reminder that professional standards must be upheld across all models of pharmacy practice, including digital and online interfaces. Pharmacists should proactively engage with the governance structures of any service they are linked with, ensuring that their involvement aligns with the GPhC’s expectations for professionalism, patient safety, and ethical conduct.

Original Case Document

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