Warning Issued for Online Prescribing Without Adequate Safeguards: GPhC Case on Prescribing Amitriptyline to Vulnerable Patients

Date of Decision: June 26, 2025

Registrant's Role: Pharmacist

Allegations:

• Prescribing amitriptyline to vulnerable patients without verifying the information provided.
• Failing to consult with patients' GPs or obtain independent confirmation of diagnoses or medical history.
• Inadequate risk assessment and safeguarding of vulnerable patients.
• Over-reliance on online questionnaires in prescribing decisions.

Outcome: Warning issued, published on the register for 12 months

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
• Standard 8 – Pharmacy professionals must speak up when they have concerns or when things go wrong
• Standard 9 – Pharmacy professionals must demonstrate leadership

Case Summary

Allegations

This case involves a pharmacist independent prescriber (PIP) working at E-Surgery and E-Pharmacy, a distance-selling model that facilitates online consultations through patient-completed questionnaires. The registrant, serving as a Lead Pharmacist Prescriber, was responsible for evaluating responses and issuing prescriptions accordingly.

Two incidents involving the prescribing of amitriptyline—an antidepressant with known sedative properties and risks of overdose—triggered concern. Patient A was prescribed amitriptyline on 16 June 2020, and Patient B on 12 June 2021. Both patients were deemed particularly vulnerable and were already under close supervision by their general practitioners due to the risks of overdose and self-harm.

In both cases, the registrant failed to verify the information provided via the online forms. Critically, there was no contact made with the patients’ GPs to confirm diagnoses or review their medical history. The registrant did not ensure that adequate safeguarding measures were in place, which was especially alarming given the vulnerability of the patients and the high-risk profile of amitriptyline in overdose scenarios.

Findings

The Investigating Committee found that the registrant’s actions fell significantly short of expected standards. Prescribing medication without confirming the appropriateness or ensuring adequate safeguarding amounted to a neglect of fundamental responsibilities as a healthcare professional.

The GPhC emphasized that “prescribing in an online environment that relies solely on a patient questionnaire with little to no safeguards in place, puts patients at risk.” The panel underscored that such practices undermine public trust in pharmacy services, particularly when vulnerable individuals are involved.

GPhC Determination on Impairment

Although the Committee did not find the registrant’s fitness to practise to be currently impaired, the seriousness of the conduct merited formal action. The registrant demonstrated remorse, provided an explanation, and evidenced engagement in Continued Professional Development. These mitigating factors weighed into the decision not to escalate to more severe sanctions.

Nonetheless, the GPhC viewed the conduct as a serious breach of professional standards. The registrant’s failure to exercise due diligence, consult other healthcare professionals, or implement robust risk assessments raised significant concerns about judgment and the safeguarding of patients.

Sanction

The Committee determined that a published warning was the appropriate and proportionate outcome. This decision aimed to both mark the gravity of the misconduct and act as a deterrent to other professionals operating in online or distance-selling pharmacy services.

“A warning is required to mark the seriousness of the issue, and to send a clear message to [the registrant], and all registered pharmacy professionals and the public, that prescribing 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 that they are expected to meet at all times.”

The warning will be published on the GPhC register for 12 months.

Key Learning Points for Pharmacy Professionals

1. Prescribing via Online Platforms Requires Robust Safeguards: Online prescribing is inherently risky, especially when handling controlled or high-risk medications like amitriptyline. Pharmacists must verify patient information and engage with other healthcare providers to ensure safe prescribing.
2. Communication with Primary Care Providers is Crucial: Failure to liaise with patients’ GPs in these cases was a critical lapse. Collaborating with other professionals is vital when dealing with complex cases or vulnerable patients.
3. Professional Judgment Must Override Convenience: Relying solely on questionnaire responses without further verification is insufficient. Pharmacists must use their professional judgment to evaluate clinical appropriateness and patient safety.
4. Safeguarding Must Always Be a Priority: In cases involving patients with mental health concerns or a history of self-harm, the duty to safeguard becomes paramount. Pharmacists must be alert to signs of vulnerability and act accordingly.
5. Training and Continuous Professional Development Matter: The registrant’s efforts to undertake additional training were viewed positively. Pharmacy professionals should proactively update their competencies, particularly in evolving models of care like distance-selling.

This case serves as a strong reminder that patient safety must always take precedence—particularly in remote settings where opportunities for oversight and real-time interaction are limited.

Original Case Document

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