Unsafe Prescribing and Dishonesty in Online Pharmacy Practice: Lessons from the Case of a Superintendent Pharmacist

Date of Decision: June 20, 2025

Registrant's Role: Pharmacist

Allegations:

Failed to follow UK prescribing guidance, including inadequate patient assessments and failure to obtain necessary medical information.
Relied on a basic online questionnaire for prescribing, enabling patients to provide false or misleading information.
Did not contact patients’ GPs before supplying prescription-only medication.
Provided unassessed and unaudited pharmacy services at a distance.
Failed to implement requirements of an Improvement Action Plan within the stipulated timeframe.
Issued around 1800 prescriptions and supplied approximately 9000 inhalers over six months without adequate oversight.
Provided misleading or inaccurate information to GPhC inspectors regarding stock levels and prescription practices.
Admitted to dishonesty and lack of integrity in several instances, including efforts to conceal the true scale of medication supply.

Outcome: Warning

GPhC Standards Breached:

Standard 1 – Provide person-centred care.
Standard 2 – Work in partnership with others.
Standard 3 – Communicate effectively.
Standard 5 – Use professional judgement.
Standard 6 – Behave in a professional manner.
Standard 8 – Speak up when things go wrong.
Standard 9 – Demonstrate leadership.

Case Summary

Allegations

This case centers on a pharmacist who served as both the Superintendent and the person with significant control at an online pharmacy. Over a period spanning from February 2020 to July 2021, the registrant engaged in a range of unsafe prescribing practices. The most serious concerns included:

Prescribing based solely on simple, manipulable online questionnaires without adequate patient assessments.
Failing to contact or seek input from patients’ GPs, omitting vital medical history, including addiction risks.
Issuing approximately 1800 prescriptions and supplying 9000 inhalers in just over six months, often in excessive quantities.
Misleading regulatory inspectors regarding stock levels and prescription practices.

Despite an Improvement Action Plan issued following a GPhC inspection in early 2020, the registrant continued with these unsafe practices. Her actions also involved multiple instances of dishonest or inaccurate representations to GPhC inspectors, including attempts to downplay the volume of inhalers being ordered and dispensed.

Findings

The panel accepted that many allegations were proven either through admission or evidence, including dishonesty. Key findings established that:

The registrant failed to conduct adequate clinical assessments and risk evaluations, violating standard professional prescribing protocols.
She dishonestly represented the nature and scale of her pharmacy operations during inspections, specifically around stock levels and prescription volumes.
She admitted to misleading the GPhC inspector in July 2021 and showed a clear intent to conceal regulatory breaches.

However, the panel also acknowledged some allegations were unproven or likely due to misunderstandings rather than deceit.

GPhC Determination on Impairment

The GPhC found the registrant’s fitness to practise impaired based on public interest grounds. The key determinants included:

Her dishonesty during a GPhC inspection.
Multiple breaches of professional standards, especially regarding patient safety and ethical conduct.
The long duration of unsafe practices despite previous regulatory interventions.

Nevertheless, the panel also noted the registrant had taken substantial steps toward remediation, including detailed reflective practice, undergoing additional training, and receiving strong endorsements from current employers and peers.

Her integrity, they concluded, could now be relied upon. While there was no ongoing risk to patient safety, her conduct had damaged public confidence and professional reputation.

Sanction

Given the mitigating circumstances and the registrant’s proactive steps to remedy the issues, the panel issued a formal warning. They judged that a suspension or removal would be disproportionate and counterproductive, especially since she had shown extensive insight and continued to provide high-quality, ethical services in her current role.

The warning, which will appear on the register for 12 months, reinforces the seriousness of her misconduct and acts as a public declaration of professional accountability.

“Your actions prejudiced public confidence in the pharmacy professions and this warning is needed to mark the seriousness of your misconduct.”

Key Learning Points for Pharmacy Professionals

Online prescribing carries significant clinical responsibility. Reliance on self-reported questionnaires without proper safeguards—such as access to summary care records or GP contact—undermines patient safety.
Volume does not excuse oversight. Issuing thousands of prescriptions in a short span without adequate risk assessment reflects dangerously poor governance, especially with high-risk medications like inhalers.
Transparency with regulators is critical. Attempting to conceal stock levels or mislead inspectors, particularly during formal assessments, is considered a severe breach of trust and integrity.
Improvement plans must be acted upon swiftly. Delays in implementing regulatory recommendations demonstrate a disregard for standards and can aggravate disciplinary outcomes.
Professional redemption requires action, not just apology. The registrant’s extensive reflection, further education, and improved practice model after the case played a vital role in mitigating the outcome.

This case stands as a stark reminder that even in the face of operational pressures—such as those intensified by the COVID-19 pandemic—pharmacists must adhere to fundamental principles of safe practice, honest communication, and continual professional development. The consequences of failing to meet these expectations, particularly in leadership roles, extend far beyond individual cases and impact public confidence in the profession.

Original Case Document

The full determination transcript is available to logged in users.