GPhC Warning for Unsafe Mounjaro Supplies to Patient With Anorexia Nervosa
Date of Decision: August 11, 2026
Registrant's Role: Pharmacist
Allegations:
- Patients’ weight and height were not independently verified before weight-management medicines were supplied.
- Insufficient reliable information was obtained about patients’ health and current medicines.
- The pharmacy relied on patients’ self-declarations to determine whether they had a current or previous eating disorder.
- Records documenting prescribing decisions were inadequate.
- Information about treatment and supplies was not shared with patients’ GPs.
- Despite repeated discussions with GPhC inspectors since 2023 about the standards and guidance applicable to distance pharmacy services, including updated guidance in February 2025, adequate safeguards were not consistently implemented.
- The deficiencies contributed to six supplies of Mounjaro to a patient with anorexia nervosa, which the GPhC considered inappropriate and unsafe.
- Although the patient had provided falsified information, the registrant did not make sufficient or adequate checks to verify its accuracy when she should have done so.
Outcome: Warning
GPhC Standards Breached:
- Standard 2 – Pharmacy professionals must work in partnership with others
- Standard 5 – Pharmacy professionals must use their professional judgement
Case Summary
Allegations
This case concerns the governance and clinical safeguards surrounding the remote prescribing and dispensing of weight-management medicines by two online pharmacy services. The registrant was both a pharmacist and pharmacist independent prescriber and occupied senior positions within the businesses: she was superintendent pharmacist of one online pharmacy and sole-trader proprietor of another. She was also involved directly in prescribing for both pharmacies.
The concerns identified by the GPhC therefore extended beyond an isolated prescribing decision. They related to the systems used to assess patients remotely and to whether sufficient safeguards were in place to ensure that weight-management medicines were being supplied only when clinically appropriate.
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- Full allegations considered by the GPhC
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Original Case Document
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