IP pharmacist suspended for unsafe online prescribing of more than 31,000 prescriptions

Date of Decision: September 23, 2026

Registrant's Role: Pharmacist

Allegations:

• The registrant prescribed and/or approved approximately 31,859 prescriptions for prescription-only medicines, including high-risk medicines and medicines requiring ongoing monitoring.
• The registrant failed to prescribe in accordance with, or pay sufficient regard to, relevant prescribing guidance from the GMC, RPS and GPhC. In particular, the registrant: failed to obtain adequate information about patients’ health before prescribing; relied principally on patient-completed online questionnaires; failed to access, or attempt to access, GP or specialist clinical records to obtain information about physical or mental health, existing medicines and addiction history; failed to arrange face-to-face or virtual consultations where required to assess clinical need; failed adequately to consider medication dependence and misuse; failed to refer patients to their GP for assessment, review or monitoring; and failed to put adequate safety-netting arrangements in place.
• The prescribing included medicines that the registrant admitted were unsuitable to prescribe solely on the basis of a patient-completed online questionnaire, including approximately: 74 prescriptions for dihydrocodeine and codeine; 22 prescriptions for co-codamol, including Zapain, Solpadol and Kapake; 125 prescriptions for Z-drugs, including zolpidem, zopiclone and Zimovane; 419 prescriptions for amitriptyline; 389 prescriptions for Circadin; 623 prescriptions for weight-loss medicines including Xenical, Saxenda and/or orlistat; 1,611 prescriptions for propranolol; 55 prescriptions for modafinil; 24 prescriptions for carbamazepine; 3,572 prescriptions for Ventolin; 445 prescriptions for cyclizine; and 641 prescriptions for promethazine.
• For patients listed in Schedule A, the registrant prescribed despite circumstances in which the registrant ought to have known that patients had repeatedly obtained high-risk medicines or medicines requiring ongoing monitoring, and failed adequately to consider dependence, misuse, review or monitoring.
• The GPhC offered no evidence on an allegation that the registrant had processed certain prescriptions in insufficient time to carry out an adequate clinical assessment.
• On 29 January 2021, the registrant prescribed amitriptyline to a patient with a history of self-harm without having sufficient information to prescribe safely.
• On 23 May 2021, the registrant prescribed levothyroxine to a patient who did not have a thyroid condition, without sufficient information to determine whether prescribing was clinically appropriate.
• The registrant prescribed amitriptyline to another patient where the medicine had already been prescribed approximately 17 times through the online pharmacy. A separate allegation concerning the time taken to review this prescription was not pursued.
• On 6 November 2019, the registrant prescribed an opioid medicine to a patient who had already received opioid medicines approximately 12 times through the online pharmacy. The patient had repeatedly stated that they were using the service because they were having difficulty obtaining a GP appointment. The registrant failed adequately to consider dependence or misuse.
• On 2 April 2021, the registrant prescribed Ventolin to a patient who declared that they had not received an inhaler prescription within the previous two months, when the registrant should have known that this information was incorrect.
• The same issue occurred again when Ventolin was prescribed to that patient on 16 May 2021.
• On 19 September 2021, the registrant prescribed Circadin to a patient who had already received the medicine approximately 16 times through the pharmacy and should have considered the possibility of dependence or misuse.

Outcome: 6 month suspension

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 8 – Speak up when there are concerns or when things go wrong
• Standard 9 – Demonstrate leadership

Case Summary

Original Case Document