Warning Issued for Inappropriate Prescribing of Propranolol via Online Platform Leading to Patient Death
Date of Decision: June 5, 2025
Registrant's Role: Pharmacist
Allegations:
- Inappropriate prescribing of a high-risk medication (propranolol) without access to Summary Care Record or independent verification
- Failure to consider patient's mental health history
- Prescribing based solely on an online questionnaire
- Prescribing decision contributed to a patient's fatal overdose
Outcome: Warning issued
GPhC Standards Breached:
- Standard 1 – Pharmacy professionals must provide person-centred care
- Standard 2 – Pharmacy professionals must work in partnership with others
- Standard 3 – Pharmacy professionals must communicate effectively
- Standard 5 – Pharmacy professionals must use their professional judgement
Case Summary
Allegations
This case centers on an incident involving the registrant, a Pharmacist Independent Prescriber employed by the Independent Pharmacy, a digital health platform supplying prescription-only medications. The pharmacy dispenses a range of medications, including high-risk drugs such as propranolol, and operates under strict clinical protocols requiring Summary Care Record (SCR) checks for certain prescriptions, particularly for higher-risk medications.
On 11 July 2021, the registrant approved a prescription for 84 tablets of propranolol 40mg for Patient A, who had requested treatment for migraines via an online questionnaire. Although the patient had previously obtained migraine treatment from the pharmacy and had provided additional responses to another prescriber, the registrant did not access the patient’s SCR nor contact the patient’s GP. The prescription was dispensed on 12 July 2021.
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- Full allegations considered by the GPhC
- Panel findings and reasoning
- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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The original determination transcript is available to registered users.
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- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
- Details of the pharmacy professionals involved