Inquests are coroner-led legal proceedings with the family at the centre of the process. They are non-adversarial, in that there are no ‘sides’ and all those involved in the case work together to assist the coroner to establish the facts. Inquests are designed to find out who the deceased was, and where, when and how (meaning by what means) they died.

Rochdale Coroners Court recently heard a jury inquest into the death of a 22-year-old woman who ordered tablets from different online pharmacies for the same drug in 2020 and 2021. Four different online pharmacies were involved. The Manchester Evening News reported that she filled in questionnaires on each of the sites used, and each time did not give consent for the details to be shared to her GP.

The greater use of online platforms, while giving wider access to healthcare, also poses further challenges. Some might say that the ability to see a patient face to face can’t be substituted. Regardless of how you feel about this, there is no going back, with the demand for online access increasing post-pandemic. However, the GPhC highlighted in late 2022 that they are continuing to identify serious patient safety concerns relating to some online pharmacies and prescribing services; as of 4 October 2022, around one-third of their open fitness to practise cases related to online pharmacies.

The GPhC has highlighted two particular areas of concern – the first being inadequate governance structures, where they noted high-risk medications or medications which require monitoring being prescribed without adequate safeguards in place. They have also noted overseas prescribers outside of UK regulatory oversight, as well as poor risk management and poor record keeping.

The second area of concern highlighted is unacceptable prescribing practices. Medicines are being prescribed to patients based on an online questionnaire alone, with no direct interaction between the prescriber and the patient or their regular prescriber. The GPhC highlights that this is of particular concern where it is part of a high volume, transactional supply of high-risk medicine. They have also raised concerns that medicines are being prescribed outside the scope of a prescriber’s practice. Furthermore, there is inadequate assessment of informed consent from patients.

Altogether, this paints a worrying picture and online pharmacies would be wise to frequently audit their provisions – it might even be useful to get your website independently audited.

It is extremely frustrating that hospital pharmacists have full access to patient health records, laboratory results and previous treatment in hospital, yet community pharmacists and those working online still do not. The GPhC clearly needs to take this into account, given that the lack of access is an impediment to care. It would be much easier if we could write on a shared record the medication that has been prescribed and provided.

Online pharmacies are expected to have systems in place to carry out an identity check appropriate for the medicine being supplied. However, the GPhC does not specify a particular technical solution for assisting with checking a person's identity. It may be that the same identity checking processes that banks use – such as photo ID and facial recognition via an app – may assist in this case.

It is common sense that a patient should not be able to choose a prescription-only medicine before there has been an appropriate consultation with a prescriber, and that the GPhC has flagged this as an issue.

A quick check online found even Levothyroxine for sale. I could then pick the strength and package size. On the first page of the website, I found nothing to suggest a consultation was needed, and it was only when I clicked to a second page that I had to fill in a questionnaire.

Patients certainly don’t get this option when they walk into their GP or community pharmacy and having medication available to pick can result in the expectation that a certain treatment will be provided. Furthermore, it is hard to reconcile this with MHRA guidance: that the appropriate management for a condition in an individual patient is for the prescriber and patient jointly to consider, and that this may include a number of medical factors as well as a range of therapeutic options.

As the GPhC has highlighted, pharmacies also need to consider the quantities they are providing. With another quick search, I was able to find 500 tablets of Piriton available in one transaction. Just because pharmacies can provide such quantities doesn’t necessarily mean they should. Perhaps it would be better for them to state that up to 500 tablets can be provided at the discretion of the pharmacist?

More worrying are offers of pharmacy only medications advertised on Groupon, a website that is known for discounts and deals rather than healthcare. I was able to find three Fluconazole 150mg capsules for just under £4. The fine print stated that it was suitable only for a certain age group and the order would be cancelled if the patient did not meet this criteria. The real problem is that patients will be purchasing the items with the expectation they can access them. Once again, I’m struggling to see how this fits with the MHRA guidance above.

Looking through the recent GPhC determinations for those running online pharmacies, a failure to have appropriate structures in place can also have personal consequences. A recent fitness to practise hearing for a responsible pharmacist who was also superintendent pharmacist of an online pharmacy resulted in conditions on their practice for 12 months. Among the concerns highlighted were:

  • A failure to audit the system which ensured patient identity was verified accurately;
  • A failure to audit the system used to prevent inappropriate supplies to patients who made repeat orders;
  • And medications sometimes being supplied prior to relevant checks being fully completed.

My best advice to those running online pharmacies is to look at your website through the eyes of a vulnerable user, and seriously ask yourself if it is designed with the patients’ best interests at heart.

Thorrun Govind – pharmacist (written in a personal capacity, separate to any organisations to which I am linked).