The General Pharmaceutical Council has placed practice restrictions on a trio of pharmacists after it found they had failed to enforce risk management measures around the supply of high-risk medicines including 3,533 bottles of codeine linctus and 9,142 packs of Phenergan via the website they ran, pharmacyonline.co.uk. 

A lengthy fitness to practise hearing that took wrapped up on October 3 resulted in conditions being placed on the licenses of Vishal Sood, Mohammed Yusuf Shabbir and Afreen Afzal after a December 2020 inspection raised wide-ranging concerns about how the business approached patient safety and how it worked with prescribing partner companies, including the controversial GenderGP. 

Mr Sood and Mr Shabbir were both directors of the Scottish company, with Mr Sood also filling the role of superintendent pharmacist at the relevant time. Ms Afzal is married to Mr Shabbir, and like him and Mr Sood worked a number of shifts as a responsible pharmacist during which she dispensed OTC and prescription medicines. However, she was not involved in running the company.

‘Entirely naïve’ about online dispensing models

The company had been trading for four months and grown its monthly turnover from £2,500 to £89,000 when the GPhC inspector visited in late 2020, having been tipped off by the MHRA that it was ordering large volumes of codeine linctus and Phenergan – which can be used together to make a commonly used and highly addictive substance known as ‘purple drank’. 

It was found that in the four months since opening, the pharmacy had sold thousands of codeine linctus bottles, including five transactions where the medicine was supplied alongside Phenergan to the same address and 12 repeat sales of codeine linctus to the same person or address. Mr Shabbir told the inspector the pharmacy charged £19.99 for codeine linctus, with the "high price" intended "to act as a deterrent". 

An opioid safety policy was in place but there was “no evidence” the business monitored its sales to enforce compliance, the inspector found – and despite shelling out £10,000 on software to assist with ID checks and prevent ‘fraudulent’ opioid purchases, the team did not have appropriate systems in place to monitor the results of these checks.

Concerns were also raised around online pathways that allowed patients to select medicines and the quantity they wished to purchase before a consultation had taken place and around the company’s failure to keep records of its communications with patients and prescribers, among other issues. 

Mr Shabbir, who had worked as a locum pharmacist before starting the business with Mr Sood, told the GPhC’s fitness to practise committee he was “entirely naïve about the very different model of online pharmacy” and “out of his depth,” with the “huge and exponential demand” for online services taking them by surprise.  

Work with GenderGP

The pharmacy also came under scrutiny for its work with GenderGP, an online prescribing service using overseas doctors to issue cross-sex hormones and other products to patient cohorts that included children. 

Out of 260 prescriptions from GenderGP that the pharmacy dispensed, 170 were for under-18s and six were for children aged 11 and under. The pharmacy subsequently stopped working with GenderGP due to its concerns around the prescriber’s business model and approach to safety. 

Mr Shabbir acknowledged that he had failed to conduct the appropriate checks and had treated gender medicine “just like a community pharmacy” rather than a “specialised area of care”. He believed GenderGP was regulated by the Care Quality Commission, which it was not, and had requested details of its policies and procedures but never received them. 

The company stopped working with GenderGP soon after the inspection, and now refuses to work with any prescriber who works solely in private practice. 

Sanctions in place for a year

Mr Shabbir is still running the business, and since the 2020 inspection has overhauled its approach to safeguarding, with a follow-up inspection in August 2022 finding that appropriate measures had been implemented. He has also undertaken extensive CPD and in-person training, and in July 2023 joined the Digital Clinical Excellence Network (DICE), which works with professional bodies to “shape the future of digital healthcare”.  

Mr Sood left the company in September 2021 and now works as a locum pharmacist, as does Ms Afzal. 

While the FtP committee noted the remedial steps taken by Mr Sood and Mr Shabbir since 2020 and found the three pharmacists were unlikely to repeat the actions in question, it determined that sanctions were necessary to recognise the seriousness of their breaches of the professional code and uphold the public interest.   

By way of sanction, the three pharmacists were told they must not work as a superintendent pharmacist and must find workplace supervisors to help them draw up personal development plans aimed at addressing areas of their practice, among other conditions of practice that will remain in place for all three for 12 months.