Online Pharmacy Safety Failings: Pharmacist’s Conditions Extended After No Evidence of Remediation
Date of Decision: October 9, 2026
Registrant's Role: Pharmacist
Allegations:
- Failure to ensure robust risk management when supplying medicines liable to abuse, misuse or overuse. These included approximately 3,533 bottles of codeine linctus, 1,015 bottles and 1,942 packs of Phenergan, 522 packs of cyclizine, and 80 bottles of Collis Browne. Failings concerned monitoring supplies, recording interventions, identifying and preventing inappropriate repeat sales, complying with the pharmacy’s opioid policy, and safeguarding vulnerable patients.
- Failure to confirm that the GP prescriber and/or Dr Felix service prescribers followed UK prescribing guidance and held appropriate registration with Healthcare Improvement Scotland where necessary.
- Allowing, or failing to prevent, prescribing without adequate clinical information and safeguards. This included shortcomings in assessing communication needs, consent and capacity, physical and mental health, medical records, addiction history, consultation requirements, dependence and misuse, repeated requests, and referral back to patients’ GPs.
- Failures within the pharmacy’s prescription service, including allowing patients to select medicines or quantities before an appropriate consultation, inadequate documentation of decisions where patients refused information sharing with their GP, and inadequate communication records.
- Failures concerning GenderGP prescriptions, including inadequate checks of regulatory arrangements, prescriber competence and compliance with UK prescribing guidance; inadequate risk assessment, counselling and monitoring; insufficient relevant knowledge and experience; and shortcomings in safeguarding and consent to contact patients’ GPs.
- Failure to ensure adequate auditing of services provided at a distance, including prescribing services.
- Failure to ensure appropriate access controls for patient records, so that access was available to, and restricted to, those with a clinical justification.
Outcome: Conditions of practice order extended for a further 12 months
GPhC Standards Breached:
- Standard 1 – Provide person-centred care
- Standard 2 – Work in partnership with others
- Standard 3 – Communicate effectively
- Standard 5 – Use professional judgement
- Standard 8 – Speak up when they have concerns or when things go wrong
- Standard 9 – Demonstrate leadership
Case Summary
Allegations
An online pharmacy’s safety failures remained unresolved at a further fitness to practise review, with the committee receiving no evidence that the registrant had addressed the deficiencies identified at the original hearing. Although the committee considered suspension and removal, it decided that another 12 months of conditions remained proportionate and would give the registrant a further opportunity to demonstrate remediation.
The underlying events occurred during the latter part of 2020. The registrant jointly owned and directed the pharmacy and worked as a responsible pharmacist. Its activities covered online sales of over-the-counter medicines, dispensing private prescriptions generated through an associated online prescribing service, and dispensing prescriptions issued by GenderGP for UK-based patients.
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- Full allegations considered by the GPhC/PSNI
- Panel findings and reasoning
- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
The original determination document is available to registered users.