Online Saxenda Prescribing Failures Led to Suspension — How a Superintendent Pharmacist Rebuilt Fitness to Practise
Date of Decision: February 3, 2026
Registrant's Role: Pharmacist
Allegations:
- Inappropriately prescribing and dispensing the weight-loss medicine Saxenda to two patients over multiple periods
- Failing to prescribe Saxenda in line with GMC, RPS, GPhC and NICE guidance, including:
- Inadequate collection of patients’ medical history
- Reliance on online questionnaires without sufficient clinical verification
- Failure to access or attempt to access GP or specialist medical records
- Failure to conduct face-to-face or adequate consultations
- Inadequate consideration of medication misuse or dependence
- Failure to inform or involve patients’ GPs appropriately
- Lack of adequate safety-netting and follow-up
- Prescribing Saxenda contrary to NICE guidance where lifestyle interventions had not been sufficiently addressed
- Governance failures as Superintendent Pharmacist, including:
- Absence of MHRA Distance Selling Logo on the pharmacy website
- Inadequate SOPs, risk assessments, audits, record-keeping, and ID verification for online prescribing
- Inadequate indemnity insurance for overseas supply
- Failure to ensure SOP compliance and GP verification during later periods of distance prescribing
Outcome: Fitness to practise no longer impaired
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 6 – Behave in a professional manner
- Standard 8 – Speak up when concerns affect patient safety
- Standard 9 – Demonstrate leadership and accountability
Case Summary
Allegations
This case centred on the registrant’s prescribing of Saxenda (liraglutide), a prescription-only GLP-1 analogue indicated for weight management under strict clinical criteria. Over several years, the registrant prescribed and supplied Saxenda through a combination of in-pharmacy and online models while acting as both an independent prescriber and Superintendent Pharmacist.
The GPhC alleged that the registrant repeatedly failed to meet the fundamental requirements of safe prescribing. In relation to Patient A, prescribing decisions were made primarily on the basis of an online questionnaire, without adequate exploration of medical history, mental health, eating behaviours, or concurrent medicines. No meaningful attempt was made to access GP records or engage in two-way clinical dialogue. There was no evidence of structured monitoring or safety-netting, despite Saxenda’s known risks, including gastrointestinal side effects, pancreatitis risk, gallbladder disease, and the potential for misuse in patients with disordered eating.
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Original Case Document
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