Warning Issued for Inadequate Oversight of High-Risk Online Ozempic Prescribing Service by Superintendent Pharmacist

Date of Decision: October 9, 2025

Registrant's Role: Pharmacist

Allegations:

Failure to risk assess or audit an online prescribing service involving high-risk medicines
Failure to verify prescriber adherence to UK prescribing guidelines
Failure to audit online questionnaire-based consultations
Failure to confirm whether patients’ GPs were contacted prior to issuing prescriptions

Outcome: Warning issued

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 their professional skills and knowledge
Standard 5 – Use professional judgement
Standard 9 – Demonstrate leadership

Case Summary

Allegations

This case concerns a superintendent pharmacist who was issued a warning by the GPhC’s Investigating Committee for serious governance failures surrounding the operation of an online prescribing service. The registrant, who is the Director and Superintendent of My London Pharmacy, initiated the service through the domain mylondonpharmacy.com around June 2022.

The key allegation centred on the pharmacist’s failure to ensure that the service operated safely and in accordance with professional and legal standards. Specifically, high-risk medications such as Ozempic (semaglutide), Rybelsus, and antibiotics for sexually transmitted infections (STIs) were prescribed and dispensed through an online system that relied entirely on patient-completed questionnaires. No robust checks were in place to confirm whether these prescriptions were clinically appropriate or safe.

Crucially, the registrant did not undertake a risk assessment or perform any audits on the prescribing practices or on the broader online service model. There was no mechanism to verify that prescribers adhered to UK clinical guidelines, nor were there checks to ensure that GPs were informed before medications were issued.

Findings

The GPhC’s inspection revealed that these oversight failures had led to patients receiving oversupplies of high-risk medicines, potentially exposing them to serious harm. The absence of a risk assessment, combined with no verification of prescriber practices or audit of consultations, created a significant governance gap.

The panel concluded that there were “examples where patients had been oversupplied high-risk medicines,” and that the structure of the online service did not incorporate essential safeguards. The risk posed by this oversight was not just theoretical—it had materialised in actual patient safety risks.

The registrant’s lack of diligence in this context was seen as a breach of several professional standards, including leadership, use of professional judgement, and person-centred care.

GPhC Determination on Impairment

While the panel did not proceed to a fitness to practise hearing (as this was resolved by warning), they noted the seriousness of the conduct. The case did not meet the threshold for impairment but required formal censure. The Investigating Committee determined that the registrant’s conduct “must not be repeated” and emphasized the critical importance of early governance planning for any pharmacy services, especially those delivered remotely.

“Proper risk assessment and governance are essential to patient safety and prescribing and/or dispensing in an online environment that relies solely on a patient questionnaire with little to no safeguards in place puts patients at risk, undermines public confidence in the pharmacy and is a serious breach of the Standards for Pharmacy Professionals.”

Sanction

The committee issued a formal warning, which will remain on the GPhC register for 12 months. The warning makes clear that any repetition of such conduct may lead to more serious regulatory consequences, potentially including referral to a Fitness to Practise Committee.

The warning specifically reminds the registrant of their ongoing duty to ensure all services—particularly digital ones—are safe, compliant, and supported by effective clinical governance systems from inception.

Key Learning Points for Pharmacy Professionals

Online services must be subject to the same governance and safety standards as in-person pharmacy services. The convenience of digital platforms does not exempt pharmacists from their professional responsibilities.
High-risk medications—such as semaglutide (Ozempic) and STI antibiotics—require stringent oversight and careful risk management. Oversupply or inappropriate supply can cause serious harm.
Risk assessments and audits are not optional. They are vital tools for ensuring patient safety and identifying areas where the service may fall below required standards.
Verification of prescriber qualifications and adherence to UK guidelines is an essential supervisory duty for Superintendent Pharmacists, particularly in private or third-party prescribing arrangements.
Communication with patients’ GPs must be considered, especially when prescribing high-risk or chronic-use medicines. Failure to integrate GP engagement increases the risk of fragmented and unsafe care.
Professional judgement and leadership must be applied proactively in online service development. Passive oversight is not acceptable; pharmacists must be hands-on in ensuring their services meet regulatory expectations.

This case is a clear reminder that digital transformation in pharmacy must be accompanied by rigorous clinical and operational governance. Pharmacy professionals launching or overseeing online services must embed safety from the start—through robust risk assessments, clear protocols, and constant quality assurance mechanisms.

Original Case Document

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