Pharmacist Warned for Unsafe Partnership with Online Prescribing Service

Date of Decision: May 19, 2025

Registrant's Role: Pharmacist

Allegations:

Entered into a contract with a third-party provider to dispense high-risk private prescriptions without conducting adequate safety checks.
Dispensed over 380 prescriptions for opioids, Z-drugs, and other misuse-prone medications over a 7-week period.
Failed to ensure that prescribing was clinically appropriate or in line with UK guidance.
Did not seek adequate indemnity advice or put in place proper SOPs or governance.
Was unaware of GPhC distance-selling guidance at the time.

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 pharmacist, acting as owner and superintendent of a retail pharmacy, entered into an agreement in June 2021 with a third-party online prescribing company. This arrangement led the pharmacy to:

Dispense over 380 private prescriptions between 16 June and 6 August 2021
The medicines involved were exclusively high-risk drugs, including opioids and Z-drugs
There was no adequate risk assessment, and the registrant failed to ensure the prescriber was operating under proper standards

He later admitted to GPhC inspectors that he was unaware of GPhC guidance on distance selling and had not ensured SOPs or risk protocols were in place.

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

Findings

The GPhC Investigating Committee found that:

The pharmacist did not exercise due professional judgement
He failed to assess or manage the clinical and regulatory risks of the partnership
He lacked awareness of his regulatory responsibilities, despite his senior position
He also failed to obtain advice from indemnity insurers, missing a crucial governance safeguard

Sanction and Warning

A formal warning was issued, with the following guidance:

“Patient safety must be at the very heart of any service he provides.”
“It is unacceptable to supply high-risk medicines in partnership with others without conducting a risk assessment for the services to be provided and taking appropriate action to mitigate risks identified.”

The warning will remain on the public register for 12 months, and future similar conduct is likely to result in stronger regulatory action.

Key Learning Points for Pharmacy Professionals

High-risk medicines (e.g. opioids, Z-drugs) require careful oversight and justified clinical need.
Online prescribing partnerships must be governed by robust risk assessments and SOPs.
Ignorance of GPhC guidance is not an excuse—owners and superintendents must stay up to date.
Indemnity insurance advice must be sought when entering novel or high-risk service models.
Leadership roles carry greater accountability—failing to manage systems safely endangers patients and public confidence.

Conclusion

This case serves as a strong warning to pharmacy owners and superintendents involved in digital health or third-party prescribing models. The GPhC made clear that dispensing high-risk medications without proper safeguards is unacceptable, regardless of whether harm occurred. A public warning was issued to uphold standards, with a clear message that future breaches may result in more serious sanctions.

Original Case Document

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