GPhC Warning Issued Over Unsafe Mounjaro Prescribing at an Unregulated Aesthetic Clinic

Date of Decision: July 16, 2026

Registrant's Role: Pharmacist

Allegations:

  • The registrant prescribed the high-risk injectable weight-loss medicine Mounjaro without requesting face-to-face consultations, contacting patients directly, or obtaining sufficient information about their physical health to assess whether continued treatment was clinically appropriate.
  • The registrant relied principally on screenshots supplied by a non-clinical colleague working within an unregulated aesthetic clinic, rather than personally accessing and reviewing the patients’ clinical records.
  • The registrant did not contact patients’ GPs or obtain other independent evidence confirming their medical histories, treatment journeys, or previous weight-loss progress.
  • The registrant did not give proper consideration to the risks of prescribing large quantities of weight-loss medication to patients who might be vulnerable or at risk of medication misuse, abuse, or dependence.
  • The registrant failed to ensure that appropriate safety-netting arrangements were in place for patients receiving high-risk medication requiring continuing monitoring and management.
  • The prescriptions did not accurately identify the organisation or entity issuing them and did not contain sufficient contact information for the prescriber.

Outcome: Warning

GPhC Standards Breached:

  • Standard 1 – Provide person-centred care.
  • Standard 2 – Work in partnership with others.
  • Standard 5 – Use professional judgement.
  • Standard 9 – Demonstrate leadership.

Case Summary

Allegations

This case concerned the prescribing of Mounjaro, described in the determination as a high-risk injectable weight-loss medication, by a pharmacist independent prescriber working at an unregulated aesthetic clinic during a short period between 28 April 2025 and 12 May 2025.

The central concern was not simply that prescribing took place remotely. Rather, the Committee identified a combination of weaknesses that, taken together, undermined the safety and reliability of the prescribing process. The registrant did not conduct face-to-face consultations, did not directly contact the patients, and did not obtain sufficient information about their physical health to determine whether continued weight-loss treatment was clinically required.

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