Pharmacist Issued Public Warning for Unsafe Independent Prescribing and Self-Medication

Date of Decision: May 8, 2025

Registrant's Role: Pharmacist

Allegations:

Carried out independent prescribing and dispensing without informing the pharmacy or obtaining authorisation, over a period of two years.
Failed to review clinical histories, document decisions, or notify patients’ GPs.
Self-prescribed and supplied himself with a year's worth of medication on three occasions, without exceptional circumstances.
Prescribed and supplied a Schedule 3 controlled drug without following legislation and guidance.
Did not maintain adequate indemnity insurance for prescribing activities.

Outcome: Formal warning issued

GPhC Standards Breached:

Standard 2 – Work in partnership with others
Standard 5 – Use professional judgement

Case Summary

Over the course of approximately two years, while working as a locum pharmacist, the registrant:

Undertook consultations as an Independent Prescriber and dispensed medication to patients directly, without informing or gaining authorisation from the pharmacy.
Bypassed governance procedures, leaving the pharmacy unable to manage or mitigate patient safety risks.
Failed to consult patient clinical records, did not properly document prescribing decisions, and did not inform GPs of medication supply.

“As a result, the pharmacy had not been able to assess and address risk to the public and patients.”

Additional Misconduct

The GPhC found several additional breaches:

The registrant self-prescribed and self-supplied a year’s worth of medication on three occasions, without exceptional clinical justification.
Prescribed and supplied a Schedule 3 Controlled Drug, failing to comply with legal and professional guidance.
Did not have adequate professional indemnity insurance in place while prescribing.

GPhC Determination on Impairment

Although the case did not proceed to a fitness to practise impairment hearing, the Investigating Committee issued a formal warning, emphasising that:

The registrant is personally responsible for reviewing clinical information, ensuring documentation is accurate, and informing other healthcare providers.
Prescribers must never pass responsibility to patients for informing their GPs.
All prescribing and supply must comply with the Human Medicines Regulations 2012, and appropriate record-keeping is mandatory.
Prescribing for oneself should only happen under exceptional circumstances, and must align with GPhC guidance (Section 4.1).

“Any similar conduct will be likely to result in further regulatory intervention.”

Sanction

A formal warning was issued with the following directions:

The registrant must adhere to prescribing guidance for both patients and self-use.
Must ensure that indemnity insurance is always in place when prescribing.
Should use patient record systems to document and communicate care clearly.
The warning will remain on the public register for 12 months.

Key Learning Points for Pharmacy Professionals

Independent prescribing requires full documentation, clinical review, and GP communication—no shortcuts are acceptable.
Prescribing and supplying medicines without pharmacy authorisation compromises patient safety and organisational governance.
Self-prescribing without exceptional circumstances is a breach of GPhC standards and must be avoided.
Indemnity insurance is not optional—it is a legal and professional requirement.
A formal warning is a serious regulatory outcome, and similar future conduct may lead to more severe sanctions.

Conclusion

This case highlights how independent prescribing, if done in isolation or without governance, can endanger patient safety and lead to regulatory consequences. The GPhC’s warning to the pharmacist reinforces that due diligence, collaboration, and transparency are non-negotiable in any prescribing activity. Pharmacy professionals must adhere to all legal, ethical, and professional frameworks, especially when prescribing for themselves or others without oversight.

Original Case Document

The full determination transcript is available to logged in users.