Warning Issued to GP Prescribing Pharmacist for Inadequate Assessments and Unsafe Prescribing Practices

Date of Decision: October 22, 2025

Registrant's Role: Pharmacist

Allegations:

Failed to conduct face-to-face assessments with patients when clinically indicated
Altered a diabetic patient’s treatment plan without sufficient communication or risk consideration
Prescribed trimethoprim to a pregnant woman without verifying pregnancy status, risking contraindicated supply

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

GPhC Standards Breached:

Standard 1 – Patient centred care
Standard 3 – Effective communication
Standard 4 – Maintaining, developing and use of their professional knowledge and skills

Case Summary

Allegations

The case revolves around a pharmacist and Independent Prescriber who was employed at a GP practice in Banbury. The registrant, operating in a patient-facing capacity, was responsible for diagnostic assessments, prescribing decisions, and medication reviews. Between 2022 and 2024, a series of concerning professional lapses led to regulatory scrutiny by the General Pharmaceutical Council (GPhC).

The specific allegations included:

Repeated failure to conduct face-to-face consultations with patients presenting symptoms that clearly required in-person assessment.
Alteration of a diabetic patient’s treatment plan without sufficiently communicating the changes to the patient or carefully considering the associated risks and potential side effects.
Prescribing the antibiotic trimethoprim to a woman who was, or could have been, pregnant—despite known contraindications during pregnancy—without adequately checking her pregnancy status.

These actions indicated breaches in the core professional responsibilities of a pharmacist, particularly around clinical assessment, communication, and safeguarding patient welfare.

Findings

The GPhC Investigating Committee assessed the matter and accepted the allegations as substantiated. The registrant’s conduct revealed serious concerns regarding clinical decision-making and professional diligence. Although the actions did not result in immediate patient harm, they posed potential risks that could have led to adverse outcomes.

The case highlighted how the registrant’s prescribing decisions lacked the necessary clinical underpinning due to insufficient diagnostic assessments. Notably, failing to conduct in-person consultations when warranted compromised the ability to gather essential clinical information, potentially leading to inappropriate treatment choices.

Additionally, the failure to confirm whether a patient was pregnant before prescribing trimethoprim—a drug contraindicated during pregnancy—represented a clinically unsafe practice that could have had serious implications for maternal and fetal health. This was especially concerning as it indicated a lapse in the application of pharmacological knowledge, which is fundamental to a prescriber’s role.

In the case of the diabetic patient, altering a treatment regimen without adequate discussion or clarity around risks demonstrated a significant communication breakdown, undermining informed consent and potentially exposing the patient to avoidable complications.

GPhC Determination on Impairment

The Committee did not proceed to a full fitness to practise hearing but instead concluded the matter was best resolved through the issuance of a formal warning. The decision indicated that while the registrant’s conduct breached professional standards, it did not necessitate a full fitness to practise impairment finding.

However, the Committee underscored the seriousness of practising outside one’s scope and the broader risks this poses to both patient safety and public confidence in the profession. They concluded that such conduct, if repeated or left unaddressed, would likely result in stronger regulatory action.

Sanction

A formal warning was deemed an appropriate and proportionate outcome. This warning is to remain on the GPhC public register for a period of 12 months. The Committee crafted a specific wording for the warning, which emphasized the registrant’s need to reflect on the seriousness of their actions:

“[The registrant] is warned that practising outside his scope could have the potential for risks to patients and may also have a negative impact on public confidence in the profession. Such matters could also be regarded as a significant departure from proper professional standards.”

The registrant was also reminded of their obligation to:

Conduct appropriate diagnostic assessments, including face-to-face consultations when necessary.
Work strictly within their scope of competence.
Ensure that prescribing decisions are based on thorough clinical evaluations and risk assessments.

The warning serves not only as a disciplinary outcome but as a formal alert that any recurrence of similar behavior will likely lead to escalated regulatory measures.

Key Learning Points for Pharmacy Professionals

This case offers several critical lessons for pharmacy professionals, particularly those in prescribing and patient-facing roles:

Face-to-Face Assessment is Sometimes Clinically Essential: Even in a digital health era, remote consultations must be clinically appropriate. When red flag symptoms or complex conditions are presented, face-to-face assessment is often essential for accurate diagnosis and safe treatment planning.
Informed Prescribing Requires Complete Clinical Information: Prescribers must take all reasonable steps to verify key patient information, such as pregnancy status, before issuing medications that carry contraindications or significant risks.
Effective Communication is Integral to Safe Care: Altering a patient’s treatment plan—especially for chronic conditions like diabetes—demands clear communication. Patients must understand the reasons for changes, potential side effects, and how to monitor their health.
Scope of Practice Must Be Respected: Pharmacists must honestly assess their competencies. Venturing into clinical territories without the requisite skills or oversight can compromise patient safety and violate professional expectations.
Warnings Are Serious Regulatory Actions: Although a warning is a lesser sanction than suspension or removal, it is still a formal indication of professional misconduct. It can impact reputational standing and must be taken as a serious impetus for reflection and improvement.

In sum, this case reinforces the critical importance of clinical prudence, thorough assessments, and communication in pharmacy practice—particularly for prescribers. It serves as a powerful reminder that regulatory expectations extend beyond knowledge alone; they encompass the judgement and care with which professional responsibilities are exercised.

Original Case Document

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