Pharmacist Suspended for Inadequate Prescribing Practices of Saxenda via Online Consultations

Date of Decision: October 20, 2025

Registrant's Role: Pharmacist

Allegations:

Inappropriate prescribing and dispensing of Saxenda
Failure to obtain adequate health information prior to prescribing
Overreliance on online questionnaires
Failure to consult or access GP medical records
Absence of face-to-face consultations in some cases
Failure to consider medication misuse and dependence
Prescribing against NICE guidance
Failure to ensure appropriate risk assessments, SOPs, and audit systems
Inadequate ID checks and record keeping
Prescribing without adequate indemnity insurance for international patients

Outcome: Suspension, 3 months with review

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 9 – Demonstrate leadership

Case Summary

Allegations

The registrant, a pharmacist and Superintendent Pharmacist at Burwash Pharmacy, faced a series of serious allegations relating to the unsafe prescribing of Saxenda, a prescription-only weight loss medication. Between 2019 and 2022, Saxenda was issued through online consultations with patients, primarily relying on self-reported questionnaires without robust clinical verification.

Concerns were raised by healthcare professionals after discovering their patients had received multiple Saxenda prescriptions without appropriate engagement with their regular GP or appropriate clinical oversight. The evidence indicated that for Patient A, there was no face-to-face consultation, no attempt to access GP records, and no thorough lifestyle assessment. The medication was prescribed despite knowledge that the patient had poor dietary habits and limited physical activity—contravening NICE guidelines which state that pharmacological interventions like Saxenda should only follow failed lifestyle changes and with close monitoring.

The registrant admitted most allegations, including failure to ensure proper SOPs, risk assessments, and record-keeping systems. The pharmacy also lacked ID checks and failed to maintain appropriate indemnity insurance for international services.

Findings

The Committee found nearly all allegations to be proven. Notably, the registrant admitted to most allegations except those related to Patient B, for whom some improvements had been implemented, such as a video consultation and notification to the GP. However, the Committee found that even in that case, prescribing still relied primarily on the questionnaire and lacked crucial verification steps like access to the patient’s Summary Care Record (SCR).

The inspection by GPhC in June 2021 uncovered significant deficiencies in clinical governance, and a follow-up inspection in May 2022 showed that several of these concerns had not been adequately addressed. The registrant’s systems lacked transparency and safeguards, such as audit trails and risk mitigation processes.

In one particularly troubling case, when asked why she didn’t access SCRs, the registrant stated she relied on “gut feeling” to determine if patients were being truthful. The Committee criticized this approach, noting it failed to meet the standards for safe prescribing.

“The Committee is satisfied that the information the Registrant obtained could not be said to be adequate if it does not include the information that could be obtained from the patient’s SCR.”

GPhC Determination on Impairment

The Committee determined that the registrant’s misconduct represented a significant departure from professional standards and posed a risk to patient safety. The registrant had breached multiple GPhC Standards, including those requiring professional judgment, collaboration with other healthcare providers, and effective communication.

The Committee acknowledged some signs of remediation, such as cessation of Saxenda prescribing and efforts to improve through a new Testosterone Replacement Therapy (TRT) model. However, it noted a lack of documentary evidence (e.g., SOPs and risk assessments) to verify that lessons had truly been learned. This concern was amplified by the registrant’s prior history—a 2015 FTP determination for similar issues, particularly poor adherence to SOPs.

While the registrant expressed genuine remorse and insight during the hearing, the Committee was not wholly satisfied that full remediation had occurred.

Sanction

Given the seriousness of the misconduct and the risk to public confidence, the Committee imposed a three-month suspension with a review. The Committee deemed a warning or conditions insufficient, particularly considering the persistence of issues after regulatory intervention in 2021 and 2022.

The Committee concluded that a period of suspension would give the registrant the opportunity to fully reflect and eliminate residual concerns. At the review hearing, the registrant is expected to provide:

Updated reflective statement
SOPs and Risk Assessments for the TRT service
Evidence of training in record keeping

Key Learning Points for Pharmacy Professionals

Robust Clinical Verification is Essential: Prescribers must access full medical histories—including GP records or SCRs—before issuing high-risk medications like Saxenda. Reliance on self-reported questionnaires is insufficient and unsafe.
SOPs and Risk Assessments Are Not Optional: Pharmacy services, especially those involving remote consultations, must be underpinned by clear, bespoke SOPs and risk management frameworks.
Communication with Other Healthcare Providers is Critical: Pharmacists must engage proactively with patients’ GPs to ensure continuity and safety of care, especially when prescribing high-risk or lifestyle-related medications.
Patient-Centered Care Requires More Than Consent: It involves fully informing patients, assessing their needs in context, and making prescribing decisions based on verified clinical information.
Learn from Past Errors: Previous regulatory findings must lead to lasting change. Failure to embed learning from past proceedings, as seen in this case, can result in repeated failings.
Record-Keeping is a Professional Obligation: Good records demonstrate accountability, transparency, and enable oversight. The absence of records undermines the integrity of the prescribing process.

This case underscores the importance of aligning innovative service models with foundational pharmacy standards and regulatory guidance. Pharmacists must ensure that business imperatives do not compromise patient safety or professional integrity.

Original Case Document

The full determination transcript is available to logged in users.