Online Pharmacy Prescribing Failures and Inadequate Clinical Safeguards Lead to 12-Month Conditions of Practice

Date of Decision: September 14, 2026

Registrant's Role: Pharmacist

Allegations:

• Overseeing an online prescribing system between 2019 and 2021 in which inadequate patient information was obtained, capacity to consent was not adequately determined, risks of dependence and misuse were insufficiently considered, frequent requests for medicines were not appropriately queried, safeguards were inadequate, and excessive reliance was placed on online questionnaires.
• Failing to ensure relevant prescribing information was shared with patients’ GPs or other healthcare professionals, and failing to document adequate justification where patients did not have a GP or would not consent to information sharing.
• Failing adequately to identify and manage the inherent risks of online prescribing, including patients deliberately supplying inaccurate information, inadequate questionnaires, repeated or prolonged prescribing, treatment of chronic conditions without appropriate GP referral, off-label prescribing and risks arising from new medicines or treatment models.
• Failing adequately to monitor and review prescribing to ensure that it was safe, justified and consistent with relevant guidance.
• Failing to implement robust patient identity checks, including in circumstances involving multiple, frequent or potentially inappropriate prescription requests.
• Failing to ensure prescribers were competent to prescribe medicines subsequently dispensed by the pharmacy.
• Failing to maintain Responsible Pharmacist records in accordance with legal requirements between 10 and 21 May 2021.
• Overseeing repeated prescribing of Z-drugs where conditions fell outside the prescriber’s practice, alternatives were not adequately considered, questionnaires did not distinguish short- and long-term insomnia, clinical checking systems were inadequate and relevant guidance was not followed.
• Overseeing opioid prescribing where prescriptions fell outside the pharmacy service or prescribers’ scope of practice, clinical checking was inadequate, generic pain questionnaires were used for differing clinical conditions, and relevant guidance and the pharmacy’s opioid policy were not followed.
• Safeguarding failures relating to emergency hormonal contraception, including inadequate identity checking and failures to ensure patients were effectively counselled about the time-sensitive nature of emergency contraception.
• Repeated supplies of cyclizine without ensuring that they were clinically justified, including multiple supplies to individual patients over periods of several months.
• Permitting tamsulosin to be prescribed and dispensed to female patients despite its licence being for male patients and it not being indicated for treating females in a primary-care environment.
• Permitting Clomid to be supplied to male and female patients despite uncertainty over the cause of infertility, inadequate automatic flagging and questionnaires that were not designed for male patients.
• Permitting levothyroxine prescribing based on online questionnaires without adequate GP consultation, clinical checks or monitoring. One patient received 168 tablets of levothyroxine 100 micrograms despite having no reported history of thyroid dysfunction, with an incompetent prescriber, no access to medical records and no adequate GP contact.
• Permitting carbamazepine prescribing without appropriate monitoring. Of particular concern was a patient with poor mental health and previous suicide attempts by prescription-medicine overdose who received carbamazepine 400 mg despite inadequate clinical checks, no GP contact, lack of appropriate monitoring and failure to recognise carbamazepine as a medicine with high-risk potential.
• Permitting metformin to be repeatedly prescribed on the basis of online questionnaires and/or without adequate clinical justification.
• Permitting repeated opioid prescribing to patients, including patients with histories of opioid abuse and one patient using aliases.
• Permitting zopiclone prescribing based on an online questionnaire and without adequate clinical justification.
• Permitting repeated supplies of emergency hormonal contraception, including Levonelle 1500 micrograms and ellaOne 30 mg, without ensuring the prescriptions were clinically justified.
• Permitting repeated bendroflumethiazide prescribing without ensuring adequate clinical justification.

Outcome: The previous nine-month suspension order was replaced with a 12-month Conditions of Practice Order.

Case Summary

Original Case Document