Pharmacist Cleared to Practise Following Suspension for Unsafe Online Prescribing Model

Date of Decision: April 28, 2025

Registrant's Role: Pharmacist

Allegations:

Approved or prescribed over 36,000 prescriptions for high-risk or monitoring-dependent medicines via UK Meds’ online platform, relying solely on online questionnaires.
Failed to perform adequate clinical assessments, access GP records, or request face-to-face consultations.
Oversaw the dispensing of nearly 55,000 prescriptions at his pharmacy without sufficient due diligence or risk assessment.
Entered into a commercial arrangement with UK Meds despite knowing their prescribing model lacked UK regulatory oversight.

Outcome: No further order. Suspension expired with no ongoing impairment.

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 5 – Use professional judgement
Standard 6 – Behave in a professional manner
Standard 9 – Demonstrate leadership

Case Summary

The registrant served as both a Prescribing Pharmacist and Superintendent/Responsible Pharmacist at his community pharmacy, while also entering a commercial partnership with UK Meds, a deregistered online pharmacy. He:

Approved 36,312 prescriptions (including 5,070 high-risk ones) without contacting patients or their GPs.
In hundreds of cases, prescriptions were approved in under one minute, with minimal clinical review.
Oversaw the dispensing of nearly 55,000 prescriptions in the pharmacy based on the same flawed model.
Prescriptions included drugs like amitriptyline, propranolol, and carbamazepine, often issued repeatedly.

A GPhC expert described the system as “unsafe,” lacking clinical safeguards or proper monitoring, and the registrant’s role was found to be primarily transactional.

“The registrant was aware the model relied on patients selecting their own medicine and completing a basic online form, but prescribed regardless.”

The committee concluded that the registrant put financial and operational interests before patient safety.

Findings of Misconduct and Initial Suspension

At the original hearing in January 2025, the GPhC determined:

The registrant’s misconduct posed a real risk to patient safety, breached pharmacy’s fundamental principles, and could bring the profession into disrepute.
Insight was limited, as the registrant initially defended the prescribing model and claimed his risk assessments were adequate.
Although no patient was found to have been harmed directly by the registrant’s actions, one patient (Patient 1) suffered serious harm under the system while taking medication approved by others in the model.

The GPhC imposed a 3-month suspension, citing the need to uphold public confidence and reinforce professional standards.

Review Hearing and Decision

At the review hearing (April–May 2025), the Committee found that:

The registrant fully accepted responsibility for his prior misconduct.
He had undertaken extensive professional reflection, supported by mentorship, and revised governance at his pharmacies.
He had completed CPPE Risk Management training, established new SOPs, and demonstrated a clear plan for safe, compliant practice.
The registrant acknowledged that his decision to work with UK Meds was influenced by financial pressure and COVID-related access issues, but accepted these were not justifications for poor clinical oversight.

“This episode has been a salutary lesson. He would be far more cautious with any business ventures in the future.”

The committee concluded that his insight had matured, and he no longer posed a risk to patients.

GPhC Determination on Impairment

The Committee concluded that:

The registrant no longer presented an actual or potential risk to the public.
His fitness to practise was no longer impaired.
Rules 5(2)(a), (b), and (c) of the GPhC Fitness to Practise Rules were no longer engaged.

“The registrant has demonstrated full insight as to why he acted the way he did… he now prioritises patient safety above all.”

No further order was made, and the suspension was allowed to expire.

Key Learning Points for Pharmacy Professionals

Patient safety must always come before business interests, especially in innovative models like online prescribing.
Automated or questionnaire-based prescribing is not sufficient for high-risk or monitoring-dependent medicines.
Regulatory oversight and clinical contact are critical—a lack of these must be a red flag.
Superintendent and Responsible Pharmacists are accountable for ensuring their pharmacy’s practices are safe and lawful.
Full and early insight matters—but it’s never too late to show reflection, remediation, and responsible change.

Conclusion

This case serves as a powerful reminder that pharmacists must never prioritise speed or revenue over patient safety, particularly in unregulated or novel delivery models. Though the registrant made serious errors of judgement, his suspension was lifted after he demonstrated mature insight, thorough remediation, and a strong recommitment to professional standards. Future pharmacy leaders can learn from his journey that reflection, accountability, and governance are the cornerstones of safe practice.

Original Case Document

The full determination transcript is available to logged in users.