GPhC Suspends Pharmacist for 12 Months Over 96,620 Online Prescriptions and Unsafe High-Risk Medicine Prescribing

Date of Decision: June 12, 2026

Registrant's Role: Pharmacist

Allegations:

• Between 20 August 2018 and 14 September 2020, the registrant prescribed or approved approximately 96,620 prescriptions through an online pharmacy, including around 63,405 prescriptions for high-risk medicines or medicines requiring continuing monitoring.
• The registrant routinely failed to follow relevant GMC, RPS and GPhC prescribing guidance. The admitted failures included: Not obtaining adequate information about patients’ health before prescribing; Relying principally on patient-completed online questionnaires; Not accessing or attempting to access GP or specialist records to establish patients’ physical and mental health, concurrent medication and addiction history; Not arranging face-to-face or virtual consultations to assess clinical need; Inadequately considering dependence, misuse and abuse; Failing to refer patients to their GPs for assessment, review or monitoring; Failing to provide adequate safety-netting.
• Between 20 August 2018 and 26 October 2019, the registrant issued approximately 50,373 prescriptions in less than one minute from the preceding approval. The panel found that this was insufficient time to read, consider and assimilate the questionnaire and other available information, assess the patient’s clinical background and decide whether GP contact or direct consultation was necessary.
• The registrant prescribed within an online model that could not adequately support safe prescribing. There was no face-to-face or virtual consultation beyond the questionnaire; information was provided primarily through that questionnaire; and, for part of 2019, patients could see which answers might prevent supply and alter those answers. The allegation that patients were permitted to pre-select the medicine, strength and quantity was not proved.
• The registrant prescribed substantial quantities of medicines considered unsuitable for questionnaire-only prescribing. Schedule A included approximately: 21,486 Z-drug prescriptions; 30,817 opioid prescriptions; 610 pregabalin prescriptions; 232 gabapentin prescriptions; 5,553 modafinil prescriptions; 762 amitriptyline prescriptions; 2,434 propranolol prescriptions.
• In identified repeat-order cases, the registrant knew or should have known that patients had previously ordered the same medicine from the online pharmacy. This element was admitted. The additional patient-specific allegations under 6.2–6.8 were not proved because evidence was not pursued in support of them.
• The allegation that approximately 13,519 prescriptions for dihydrocodeine were issued despite the registrant knowing or being expected to know of previous dihydrocodeine supplies was not proved.
• The registrant prescribed 100 tablets of codeine 30 mg to a patient with poor mental health and a history of drug misuse, despite repeated previous orders and without adequate clinical information, GP-record access, direct consultation, dependence assessment, referral or safety-netting.
• On five occasions, the registrant prescribed 100 tablets of dihydrocodeine 30 mg to a patient with a history of opioid dependence. The prescribing occurred despite repeat orders and without the safeguards required for appropriate opioid prescribing.
• The registrant prescribed zopiclone 7.5 mg, dihydrocodeine 30 mg and pregabalin 150 mg to a patient with poor mental health, self-harm, suicidal thoughts and drug misuse, without obtaining a complete clinical picture or adequately addressing the risks.
• The registrant prescribed 100 tablets of dihydrocodeine 30 mg to a patient with poor mental health who had repeatedly obtained the same medicine, without adequate assessment, monitoring or liaison with the patient’s GP.
• The registrant prescribed 28 tablets of amitriptyline 50 mg to a patient with a history of poor mental health, overdose and self-harm. The patient subsequently used amitriptyline in an overdose requiring intensive-care treatment. The determination did not find that the registrant’s prescription legally or medically caused the overdose, but the circumstances illustrated the serious risks associated with prescribing a medicine with high toxicity in overdose without reliable corroboration or clinical safeguards.
• The registrant’s prescribing was transactional: patient requests were processed by reference to an online questionnaire rather than through an individualised prescribing assessment conducted in accordance with professional guidance.
• The registrant’s approach lacked integrity because financial gain was placed above patient safety. The panel found the financial-motivation element proved. It did not find that the registrant had acted from an eagerness to please the employer, noting that the registrant had continued to refuse or refer some requests despite commercial pressure.

Outcome: The registrant was suspended from 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 4 – Pharmacy professionals must maintain, develop and use their professional knowledge and skills.
• Standard 5 – Pharmacy professionals must use their professional judgement.
• Standard 6 – Pharmacy professionals must behave in a professional manner.
• 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

Original Case Document