Pharmacist Suspended for Unsafe Online Prescribing Practices Leading to Multiple Deaths

Date of Decision: February 4, 2025

Registrant's Role: Pharmacist

Allegations:

• Prescribed medicines on 62,689 occasions using an online questionnaire-based model.
• Prescribed high-risk medicines on 4,859 occasions using an online questionnaire-based model.
• Failed to obtain adequate patient information and relied on online questionnaires.
• Did not access or attempt to access patients' GP records.
• Failed to request face-to-face consultations.
• Did not consider medication dependence and misuse.
• Prescribed in circumstances where the prescribing model was incapable of supporting safe decisions.
• Prescribed a significant portion of prescriptions without sufficient time for clinical evaluation.
• Prescribed propranolol and amitriptyline in unsafe circumstances leading to patient deaths.
• Transactional approach to prescribing, prioritizing commercial transactions over patient safety.

Outcome: Suspension for 12 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 6 – Behave in a professional manner
• Standard 8 – Speak up when they have concerns or when things go wrong
• Standard 9 – Demonstrate leadership

Case Summary

The case involved a pharmacist who, during his tenure with UK Meds Direct Limited, prescribed medicines on 62,689 occasions using an online questionnaire-based model. Of these, 4,859 prescriptions were for high-risk medicines. The pharmacist failed to obtain adequate patient information, relied heavily on online questionnaires, did not access patients’ GP records, and failed to conduct face-to-face consultations. His prescribing practices were deemed unsafe, particularly as the model used was incapable of supporting safe prescribing decisions. Additionally, he prescribed medications without sufficient time for clinical evaluation, leading to unsafe practices that contributed to patient deaths.

Findings
The GPhC panel found that the pharmacist’s actions breached multiple standards, including providing person-centred care, working in partnership with others, and using professional judgment. The panel noted that the pharmacist’s approach was transactional, prioritizing commercial transactions over patient safety. The pharmacist admitted to all allegations, acknowledging his reliance on the online model and his failure to adhere to professional guidelines.

GPhC Determination on Impairment
The GPhC determined that the pharmacist’s fitness to practice was impaired due to his misconduct. The panel highlighted the risk of repetition and the need to maintain public confidence in the profession. Despite the pharmacist’s recent insight and remediation efforts, the panel found his insight to be incomplete and fragile, warranting a finding of impairment to protect the public and uphold professional standards.

Sanction
The pharmacist was suspended for 12 months with a review. The panel considered the seriousness of the misconduct and the need to send a clear message about the unacceptability of such practices. The suspension was deemed necessary to protect the public and maintain confidence in the profession, while allowing the pharmacist time to continue his remediation and develop further insight.

Key Learning Points for Pharmacy Professionals
This case underscores the importance of adhering to professional guidelines and ensuring patient safety in prescribing practices. Pharmacy professionals must prioritize patient-centered care, obtain comprehensive patient information, and engage in effective communication. The case also highlights the risks associated with online prescribing models and the need for robust safeguards to prevent unsafe practices. As the panel noted, “The reputation of the profession is more important than the fortunes of any individual member.” Pharmacy professionals must remain vigilant and uphold the highest standards of practice to maintain public trust.

Original Case Document

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