Pharmacist Warned for Failing to Safeguard High-Risk Medicines in Online Dispensing Scheme

Date of Decision: May 19, 2025

Registrant's Role: Pharmacist

Allegations:

Oversaw the dispensing of over 380 private prescriptions for high-risk medicines (e.g. opioids, Z-drugs) in under two months.
Failed to identify or manage risks associated with online prescribing from a third-party company.
Did not confirm the appropriateness of the prescribing process, or whether repeat and high-dose prescriptions were being monitored.
Did not ensure adequate SOPs or governance procedures were in place.
Admitted he was unaware of GPhC guidance relevant to distance selling.

Outcome: Formal warning issued

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 2 – Work in partnership with others
Standard 5 – Use professional judgement
Standard 9 – Demonstrate leadership

Case Summary

The case concerns the registrant’s role as Responsible Pharmacist at a community pharmacy in June–August 2021. The owner of the pharmacy had entered into an agreement with a third-party online prescribing service.

Between 16 June and 6 August 2021, the pharmacy dispensed over 380 prescriptions, all involving:

Medicines liable to abuse or misuse, including opioids, Z-drugs, and others categorised as high-risk.
Prescriptions issued via questionnaires without face-to-face consultation or robust safeguards.

The registrant:

Failed to carry out a risk assessment or ensure that the prescriber followed appropriate clinical guidance.
Did not monitor prescribing decisions, or make clinical interventions when appropriate.
Was unaware of any measures to detect over-ordering or unsafe repeat requests.
Did not ensure SOPs were in place for the supply of these high-risk medicines.

“This put patients at real risk of harm from the supply of the medicines.”

GPhC Determination on Conduct

The Investigating Committee found:

The registrant’s conduct compromised patient safety.
He did not demonstrate adequate leadership, judgement, or clinical oversight.
There was no evidence of wilful misconduct, but serious regulatory failings.

“It is unacceptable to supply high-risk medicines in partnership with others without conducting a risk assessment and taking appropriate action.”

Sanction

The GPhC issued a formal warning, which:

Is published on the GPhC register for 12 months
States that similar future conduct is likely to result in stronger regulatory action

The warning included a reminder that the registrant must:

Place patient safety at the heart of all services
Stay up to date with guidance from GPhC and relevant bodies
Ensure all medicine supply is safe and clinically appropriate

Key Learning Points for Pharmacy Professionals

High-risk medicines require active oversight, not passive fulfilment of third-party requests.
Pharmacists must perform due diligence when working with online prescribers.
Clinical appropriateness must be verified, especially for repeat, high-dose, or abuse-prone drugs.
Standard operating procedures and risk assessments are mandatory for new or unusual dispensing arrangements.
Ignorance of GPhC guidance is not a defence—pharmacists must keep their knowledge current.

Conclusion

This case highlights the risks of entering dispensing partnerships without robust governance, risk assessment, or professional oversight. The pharmacist’s failure to uphold these responsibilities—especially for high-risk drugs—resulted in a formal public warning. It stands as a reminder that regulatory awareness, leadership, and patient protection must be at the forefront of all pharmacy services.

Original Case Document

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