Pharmacist Issued Warning for Unsafe Dispensing Linked to Online Prescribing Platform

Date of Decision: April 28, 2025

Registrant's Role: Pharmacist

Allegations:

Dispensed high-risk and prescription-only medicines based on online questionnaires alone, without proper clinical safeguards.
Failed to conduct due diligence on the online prescribing service and its prescribers.
Did not ensure appropriate risk assessments, GP involvement, or monitoring systems were in place.
Failed to properly maintain the private prescriptions register and did not uphold patient safety standards.

Outcome: Formal warning issued

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 things go wrong

Case Summary

The registrant was the Superintendent and Responsible Pharmacist of a pharmacy that, from September 2021 to August 2022, provided dispensing services to an online prescribing platform. The platform issued prescriptions based almost entirely on patient questionnaires, without any clinical consultation or contact with the patient’s GP.

The pharmacy dispensed medicines such as:

Modafinil, amitriptyline, propranolol,
Weight-loss treatments, asthma medications, and other drugs requiring ongoing monitoring and clinical review.

The GPhC found that the registrant:

Did not perform due diligence to assess the regulation and safety of the prescribing service.
Failed to confirm the clinical appropriateness of medicines before dispensing.
Did not conduct risk assessments or ensure that prescribers followed UK clinical guidance.
Failed to ensure that medication records were properly maintained, including incomplete entries in the private prescription register.
Did not confirm that patients were being monitored, nor that care was coordinated with the patients’ other healthcare providers.

Findings

The GPhC Investigating Committee found that the registrant’s actions:

“Put public safety at risk and undermined confidence in the profession.”

Although there was no direct evidence of harm, the registrant’s approach lacked the safeguards necessary to ensure patient safety, especially for medicines requiring monitoring.

The Committee found breaches of multiple GPhC standards and stated:

“Dispensing medicines deemed high-risk or requiring ongoing monitoring… based solely on online questionnaires must not occur unless robust systems are in place.”

GPhC Determination on Impairment

The registrant was found not to be currently impaired, as there was no suggestion of dishonesty or patient harm. However, the GPhC concluded that the conduct:

Fell significantly below professional expectations
Warranted a formal regulatory response
Could damage public confidence in the profession if unaddressed

Sanction

A formal warning was issued, to remain on the GPhC register for 12 months. The warning emphasised:

The importance of verifying the safety and regulation of online prescribing platforms.
The need to ensure clinical oversight and appropriate record-keeping.
That patient safety must take priority in any pharmacy service setting.

Key Learning Points for Pharmacy Professionals

Online prescriptions must be clinically appropriate and safely managed—questionnaires alone are insufficient.
Due diligence is essential before partnering with third-party services.
Coordination with GPs and other care providers is a fundamental expectation.
Proper record-keeping, especially for private prescriptions and high-risk medicines, is non-negotiable.
Warnings serve as public markers of unacceptable professional conduct, even without impairment.

Conclusion

This case highlights that even without direct harm or intentional wrongdoing, pharmacists must ensure robust clinical safeguards when working with online services. Dispensing based solely on automated questionnaires is incompatible with person-centred care and risks undermining public trust. The 12-month warning serves as a reminder that pharmacy professionals are accountable for the safety and quality of services they provide or supervise.

Original Case Document

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