Warning Issued Over Online Dispensing Failures: Key Safeguards Ignored by Superintendent Pharmacist

Date of Decision: August 13, 2025

Registrant's Role: Pharmacist

Allegations:

Failed to carry out sufficient due diligence before dispensing for an online prescribing service.
Did not verify the regulatory status or safety protocols of the prescribing service.
Did not ensure the existence of procedures for prescribing, clinical monitoring, or managing overprescribing.
Failed to confirm processes for verifying patient identity and medical history.
Dispensed without access to consultation notes or completed patient questionnaires.
Did not assess patient consent regarding sharing information with GPs.
Failed to conduct risk assessments and audits of the dispensing practice.
Dispensed medicines without confirming clinical appropriateness or monitoring.

Outcome: Warning 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 5 – Pharmacy professionals must use their professional judgement

Case Summary

Allegations

This case concerns a pharmacist who served as director, Superintendent, and at times Responsible Pharmacist for a pharmacy engaged in dispensing medicines through an online prescribing service between June 2023 and July 2024. The allegations arose from systemic failures in ensuring the safety, regulatory compliance, and clinical appropriateness of that service.

The registrant neglected to carry out sufficient due diligence before engaging with the online service. Critically, they did not verify whether the service was properly regulated, nor did they assess whether there were written policies on prescribing protocols, patient monitoring, clinical intervention recording, or strategies for managing overprescribing and misuse-prone medications.

Further, the registrant did not verify how the service confirmed patient identity or medical history. They failed to ensure their pharmacy had access to essential clinical information, such as consultation notes or patient questionnaires. Consequently, the pharmacy operated without a full picture of the patient’s clinical context, undermining its ability to ensure safe and effective dispensing.

There was also a lack of clarity on how patient consent was handled—specifically regarding the sharing of prescribing decisions with GPs or NHS prescribers. No risk assessments or audits were conducted to evaluate the safety of the dispensing practice.

Findings

The Investigating Committee found that these lapses represented serious breaches of professional responsibilities, especially for someone in a leadership role. The registrant’s inaction risked patient safety by allowing medicine to be dispensed without sufficient clinical oversight. The lack of systems to verify essential patient information or monitor ongoing treatment showed a disregard for core pharmacy standards.

The Committee emphasized that the registrant’s pharmacy did not have access to critical prescribing details and lacked understanding of how decisions were made or monitored by the online service. These shortcomings were particularly concerning given the potential for misuse or harm when dealing with medications liable to abuse.

“To dispense medicines without proper safeguards in place puts public safety at risk and can undermine confidence in the profession.”

GPhC Determination on Impairment

Although the case did not proceed to a full fitness to practise hearing, the GPhC Investigating Committee deemed the conduct sufficiently serious to warrant regulatory action. They concluded that the registrant’s failure to establish and maintain proper safeguards compromised the principles of patient-centred care, interprofessional collaboration, and clinical judgement.

The Committee determined that a warning was a proportionate response in this instance, especially given that the registrant was reminded of the professional expectations and the potential consequences of repeated failings.

The Committee directed that this warning be placed on the public register for 12 months to serve both a deterrent and educational function.

Sanction

The sanction imposed was a formal warning. This outcome reflects the GPhC’s view that, while the conduct did not necessitate removal or suspension from the register, it was nevertheless unacceptable and merited public censure.

The warning included a clear directive:

“Pharmacy owners and Superintendent Pharmacists must ensure that any services with which they choose to work are appropriately regulated and safe.”

It also noted that any recurrence of such conduct would likely trigger more serious regulatory intervention.

Key Learning Points for Pharmacy Professionals

Due Diligence Is Non-Negotiable: Pharmacists must verify that any third-party service—especially online prescribers—is compliant with all regulatory and clinical standards. This includes confirming the existence of documented procedures, consent mechanisms, and monitoring systems.
Information Access Is Essential: Before dispensing on behalf of another service, pharmacists must ensure they have access to consultation records and patient history. Operating without this information is professionally irresponsible.
Patient Safety Comes First: The safety of the patient must guide all professional actions. Dispensing medication without adequate clinical context or monitoring structures compromises this core principle.
Risk Assessment and Auditing Must Be Routine: Ongoing evaluation of dispensing practices through structured audits and risk assessments helps ensure continued safety and compliance.
Leadership Brings Greater Responsibility: Those in Superintendent or Responsible Pharmacist roles bear additional obligations. Leadership does not only confer authority—it imposes a duty to uphold the highest professional standards across all areas of practice.

This case serves as a stark reminder that shortcuts in verification and oversight, particularly when collaborating with online services, can endanger patient safety and erode public trust in the profession.

Original Case Document

The full determination transcript is available to logged in users.