Pharmacist Issued Warning for Unsafe Online Prescribing of High-Risk Medicines

Date of Decision: May 19, 2025

Registrant's Role: Pharmacist

Allegations:

Approved prescriptions for high-risk medications (e.g. opiates, Z-drugs, propranolol, amitriptyline, weight-loss and asthma medicines) based solely on online questionnaires.
Failed to obtain confirmation of diagnoses or medical histories from patients’ GPs or other independent sources.
Did not take appropriate steps to safeguard vulnerable patients or consider risks of abuse and dependence.
Prescribed to patients who had already received multiple similar prescriptions from other prescribers on the same platform.

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

Case Summary

The registrant, a Pharmacist Independent Prescriber, worked for an online pharmacy platform between 29 July 2019 and 11 November 2019. The platform provided prescriptions almost entirely through automated questionnaires, without routine clinician contact.

The medications prescribed included:

High-risk medicines such as opiates, z-drugs, amitriptyline, and propranolol
Weight-loss and asthma medications, which require ongoing monitoring and safety checks

The registrant:

Relied solely on patient responses to questionnaires to make prescribing decisions
Did not contact GPs or verify diagnoses, even for high-risk or repeat patients
Did not adequately assess risk of abuse, vulnerability, or overuse
Continued to approve prescriptions for patients with known repeated use through the platform

GPhC Determination on Conduct

The Committee found:

The registrant’s conduct posed a risk to patient safety, especially given the nature of the medicines involved
There was no evidence of appropriate safety netting or system checks in place
Prescribing in such a context, without due diligence, could undermine public trust in the profession

“Prescribing decisions based solely on an online questionnaire for medications deemed high-risk… must not be made unless robust systems are in place.”

“To prescribe in an unsafe online environment puts public safety at risk and can undermine confidence in the profession.”

Sanction

The Investigating Committee issued a formal warning, not a finding of impairment. This warning:

Will be published on the public register for 12 months
Serves as a clear message that future similar conduct will likely lead to more serious sanctions

Key Learning Points for Pharmacy Professionals

Online prescribing requires additional safeguards, especially for high-risk medicines.
Verification of diagnosis and medical history is essential—GP or third-party confirmation should be routine.
Prescribing without monitoring, particularly to repeat or vulnerable patients, poses significant safety risks.
Independent prescribers are accountable for their decisions, regardless of platform limitations.
Warnings carry reputational and regulatory consequences and serve as formal disciplinary action.

Conclusion

This case highlights the dangers of unregulated online prescribing, especially where high-risk medications are involved. The pharmacist’s failure to apply clinical judgement, seek corroborating evidence, or implement safety protocols resulted in a formal warning from the GPhC. The case serves as a reminder that convenience must never come at the cost of safety—especially in digital health.

Original Case Document

The full determination transcript is available to logged in users.