Pharmacists working as online prescribers should beware the ‘red flag’ of a patient refusing to allow them to contact their GP, the Pharmacists’ Defence Association (PDA) has warned.

It has issued guidance to pharmacist prescribers working in online settings to minimise risk both to themselves and to their patients.

And it urged the General Pharmaceutical Council (GPhC) to extend guidance relating to the safe online prescribing of high-risk medicines to all medicines that are highly toxic in overdosage.

This follows the publication earlier this year of a coroner’s report into the death of Ania Sohail, a young woman who took an overdose of medicines purchased from several different online pharmacies.

The Regulation 28 report, intended to make recommendations to prevent future deaths, was drafted by the coroner to official bodies including the General Pharmaceutical Council (GPhC), the Care Quality Commission, the Medicines and Healthcare products Regulatory Agency (MHRA) and online pharmacy UK Meds.

It raises concerns that there is no integrated system in place to show prescribers what has been dispensed by other online pharmacies, or to require online pharmacies to share information with the patients’ GP, allowing patients to place multiple orders even when it is potentially harmful to do so.

The GPhC already has guidance for online pharmacies relating to the prescribing of ‘high-risk’ medicines such as opioids, sedatives, laxatives, and gabapentinoids, where there is a risk of abuse, overuse, misuse or addiction and where ongoing monitoring is important.

The PDA has now called for that guidance to be extended to all medicines that may not be considered ‘high-risk’ in normal usage but are toxic in overdosage.

This would require online prescribers to only prescribe these medicines if they have safeguards in place including:

  • ‘Robust processes’ to check the identity of the person
  • Asking for the contact details of the patient’s regular prescriber, such as their GP, and for their consent to contact them about the prescription
  • Contacting the GP for confirmation that that the prescription is appropriate for the person and that appropriate monitoring is in place.
  • Recording their justification for prescribing without contacting the patients’ regular prescriber if they feel there are exceptional circumstances

The PDA also set out its own advice to online prescribers. In particular, it said that patients refusing to allow the prescriber to contact their GP was a ‘red flag’.

‘It cannot be in patients’ best interests to allow almost unchecked access to prescription medicines which can cause fatalities when misused, with no requirement to alert GPs to the proposed supply,’ the PDA said.

And it added that ‘a common feature’ in the case of Ania Sohail and other similar cases was that the pharmacist had ‘no interaction whatsoever with the patient, instead relying solely on a questionnaire completed online’.

‘Ania Sohail’s GPs had no idea that she was obtaining online supplies of a potentially harmful medication until they received the sad news of her death from the local hospital. Given her history of self-harm, they would most likely have been able to advise against supply, had they been contacted,’ the PDA added.

It advised online prescribers that if a patient refused to allow the pharmacy to contact their GP, the prescriber should contact the patient via phone or video call and ‘gently probe’ as to why consent had been refused.

The prescriber should also inform the patient of the ‘risks to their safe care and difficulties presented to other prescribers’ if they refused to allow GP contact, and should be encouraged to review their decision.

The prescriber should also verify the accuracy of the information presented on the questionnaire at the same time, the PDA said.

And they should fully document their thought process for deciding whether or not to prescribe medicines that could be highly toxic in overdose to the patient.

If they decide that the risks outweigh the benefit of prescribing, they should inform the patient and signpost them to their GP or another suitable healthcare provider.

The PDA added: ‘The pharmacists called to give evidence at Ania’s inquest will have to live with the knowledge that she ended her life with medicines they prescribed for her.’

And it said that it wanted to improve safety and alert pharmacists to the risks associated with online prescribing that omits direct patient contact and communication with the GP, ‘so that they can put in place appropriate mitigations which may prevent them from finding themselves in a similar distressing situation’.