Pharmacist’s Online Prescribing Misconduct Leads to Suspension Review
Date of Decision: June 17, 2025
Registrant's Role: Pharmacist
Allegations:
- Prescribing outside the scope of competence (e.g., chronic pain, dental infections, anxiety)
- Inadequate patient assessment, failure to obtain full medical history or refer to GP
- Insufficient safeguards against medication misuse
- Specific poor prescribing practices for 14 patients involving high-risk drugs (e.g., dihydrocodeine, zopiclone)
- Contributing to harm in cases involving patients P and Q
Outcome: Suspension to lapse on expiry; fitness to practise no longer impaired
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 8 – Speak up when they have concerns or when things go wrong
- Standard 9 – Demonstrate leadership
Case Summary
Allegations:
This case centers on a pharmacist who served as an Independent Prescriber for an online service, Instant E-Care Ltd, between March 2015 and May 2019. She was found to have prescribed medication—including opioids and other controlled substances—for conditions beyond her area of competence, such as chronic pain and anxiety. Notably, she failed to obtain adequate clinical information, review patients’ medical histories, or refer patients to their GPs. She relied on online questionnaires that could be easily manipulated by patients.
Two significant patient cases, referred to as Patient P and Patient Q, were highlighted. Patient P exploited the system by using multiple identities to obtain dihydrocodeine, which contributed to ongoing addiction and family distress. Patient Q died in 2020 from drug-related causes, having used multiple online pharmacies, including the one where the registrant worked. Although the registrant was not directly blamed for the death, her actions were described as “a link in a chain” that led to the tragedy.
Findings:
The Fitness to Practise Committee found extensive breaches of GPhC standards, particularly around professional judgement, communication, safeguarding, and patient-centered care. They emphasized that the registrant, despite over 20 years of experience and understanding of proper clinical practice, had disregarded these standards. The prescribing was labeled “transactional,” reflecting a model where prescriptions were issued with minimal clinical oversight.
The original hearing acknowledged the registrant’s sincerity, remorse, and lack of financial motive. However, they also noted the absence of a clear explanation for why such misconduct occurred, raising concerns about potential future risk.
GPhC Determination on Impairment:
At the June 2025 review, the Committee concluded that the registrant’s fitness to practise was no longer impaired. They acknowledged the registrant’s deep and structured reflective work, her commitment to professional standards, and the insight gained during her suspension. Evidence included personal development plans, mapping to GPhC and Royal Pharmaceutical Society (RPS) prescribing frameworks, character references, and CPD activity.
“My prescribing was described as ‘transactional,’ and I now fully understand how dangerous that was. These serious and repeated failings put patients at risk.”
the registrant
Despite the registrant’s continued inability to pinpoint exactly why she had acted as she did, the Committee felt that her sustained insight, acknowledgment of wrongdoing, and her clear intent never to repeat such behaviour mitigated this concern. They were particularly persuaded by her change in attitude and her commitment to remaining in an academic, non-clinical role.
Sanction:
Given the successful demonstration of insight and remediation, the Committee decided not to extend the suspension beyond its current expiration. They ruled that public confidence and professional standards had been upheld through the initial suspension and the registrant’s proactive conduct during that period.
Key Learning Points for Pharmacy Professionals:
- Prescribing Responsibility Is Personal: Pharmacists must take personal responsibility for every prescription issued. Compliance with flawed institutional protocols does not excuse unsafe practices.
- Scope of Practice Must Be Respected: Prescribing outside one’s training—especially in areas like chronic pain and mental health—poses significant risks to patient safety.
- Guarding Against Misuse: Relying on easily manipulated systems (e.g., online questionnaires) for prescribing decisions fails to meet professional safeguarding duties.
- Insight and Remediation Are Critical: A reflective, evidence-based approach to understanding and learning from errors plays a vital role in demonstrating professional rehabilitation.
- Academic Roles Also Require High Standards: Even outside direct patient care, pharmacy professionals must maintain a high standard of conduct and use their roles to educate others about professional responsibilities.
This case is a sobering reminder of the risks posed by online prescribing without adequate clinical oversight, and the need for pharmacists to uphold professional standards regardless of the setting or system they work within.
Original Case Document
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