Pharmacist Suspended for Governance Breakdown in High-Volume Private Prescribing Case involving Patient Death

Date of Decision: February 16, 2026

Registrant's Role: Pharmacist

Allegations:

• Between 2 January 2020 and 31 December 2021, the registrant prescribed and/or approved prescriptions for medicines requiring ongoing monitoring and/or medicines unsuitable for online questionnaire-based prescribing.
• The registrant failed to prescribe in accordance with relevant GMC, RPS and GPhC guidance by: Not obtaining adequate patient health information; Relying primarily on online questionnaires; Failing to access Summary Care Records (SCR), GP or specialist records; Not conducting face-to-face or remote consultations; Failing to consider risks of dependence or misuse; Failing to refer patients to their GP appropriately; Failing to implement adequate safety-netting.
• Between February and July 2021, the registrant failed to ensure the pharmacy’s prescribing model supported safe prescribing, including: No consultations beyond questionnaires; A manipulable questionnaire system; Inadequate repeat/early order checks; No audits or risk assessments; Inadequate ID verification; No records of prescribing decisions or SCR access.
• Between July 2021 and October 2022, similar systemic failures continued, including inadequate monitoring of prescriber compliance and dispensing checks.
• The registrant issued a significant volume of prescriptions in timeframes insufficient for safe clinical evaluation.
• On multiple occasions in March, April and May 2021, the registrant prescribed Propranolol 40mg to Patient A despite repeated prior supplies and failed to notify the patient’s GP or safeguarding professionals.

Outcome: 12-month suspension with review (Interim Suspension imposed)

GPhC Standards Breached:

• Standard 1 – Provide person-centred care
• Standard 2 – Work in partnership with others
• Standard 3 – Communicate effectively
• Standard 4 – Maintain, develop and use professional knowledge and skills
• Standard 5 – Use professional judgement
• Standard 9 – Demonstrate leadership

Case Summary

Original Case Document