Pharmacist suspended for nine months over online supply of high-risk drugs
The pharmacy regulator has suspended a superintendent pharmacist for nine months for failures to supply high-risk medicines safely from an online pharmacy.
Taheebat Damilola Victoria Esulaja, registration number 2086465, was handed a nine-month suspension following a General Pharmaceutical Council (GPhC) fitness-to-practise (FtP) hearing held last month (April 5-6).
Ms Esulaja was the superintendent pharmacist of SQ Invest Ltd from December 31, 2018, which trades as www.mydoctornow.co.uk, according to a determination document published last week.
She was suspended for "misconduct” in relation to the “dispensing and supply of high-risk drugs containing codeine, dihydrocodeine, zopiclone and zimovane”, it said.
The regulator accepted that she had no previous FtP involvement and “co-operated fully” with the process, as well as providing “positive testimonials”.
But it stressed that she was “responsible” for the pharmacy as superintendent and that the medicines in question are “known to be open to abuse”.
The committee heard how she allegedly failed to “ensure that sufficient checks were made when supplying medications”, with the pharmacy placed under a condition for “system-wide failures in the operation of the pharmacy which presented a serious risk to patient safety”.
In November 2019, the GPhC imposed conditions on the pharmacy that said it “must not sell or supply any controlled drugs from Schedule 1 to 5 of the Misuse of Drugs Regulations 2001” following an unannounced inspection, the regulator said.
The hearing heard that the risks “were heightened by the nature of the services provided by the pharmacy, which involved the dispensing and supply of high-risk medicines, including opioids and z-drugs at a distance, against prescriptions issued by non-UK prescribers”.
Medicines supplies “solely” based on a questionnaire
The determination said that Ms Esulaja failed to ensure that medicines supplied were “appropriate and safe” such as by ensuring patient identity was verified, including failing to “detail and record random checks”.
Ms Esulaja also failed to audit the system used to prevent “inappropriate supplies to patients who had been restricted from ordering or where people had submitted incorrect GP details”, it added.
The pharmacy website enabled people to choose the strength and quantity of medicines before a consultation, and drugs – including high-risk medicines – “were supplied solely based on a questionnaire” that patients completed, it said.
Ms Esulaja “supplied patients with high-risk medicines without ensuring their regular doctor agreed with the supply and, in the absence of a GP or regular prescriber, did not ensure that the prescriber made a clear record to justify their decision to prescribe”, according to the hearing document.
The regulator said that the pharmacy had no “clear policies on the number of supplies of opiates that can be made before contact with the patient’s regular healthcare provider is needed”.
And its IT system did not prevent unauthorised personnel from accessing and amending records and prescriptions, it added.
Further, Ms Esulaja did not ensure that prescribers “followed UK national guidelines” and were “appropriately registered in their home country”, or that “all services, including for prescribers, were covered by appropriate indemnity insurance”, it said.
The regulator found that Ms Esulaja “failed in her fundamental obligations as a registered pharmacy professional to act in the best interests of patients” and that this “raised the risk of harm to vulnerable patients”.
It added that she “did not appear…to have more than the very vaguest idea of what was happening at the pharmacy”, saying that the committee was “astounded to hear” that she “had no idea that 70% of the prescribing was for opioids and another 5% was for z-drugs”.
The committee said it was “baffled and very concerned” when Ms Esulaja stated that when took on the superintendent role she was “clueless”, had “no idea what it entailed” and she thought she would “learn the ropes” as she went along.
The pharmacy’s “systems and processes for checking that it was supplying these drugs safely and appropriately were woefully unsatisfactory”, the GPhC said.
Ms Esulaja’s “practice while in the role of [superintendent] at the pharmacy was shockingly and seriously reprehensible, amounting to a reckless disregard for the welfare and safety of the end-users of the medications prescribed and dispensed by the pharmacy”, it added.
And it said that she “abused [her] position of trust” as a pharmacist by her “lackadaisical and reckless conduct”.
“Not the most serious” online pharmacy failing
However, the regulator acknowledged that Ms Esulaja, had no “previous fitness to practise involvement, she co-operated fully with this process, has provided positive testimonials, and made prompt admissions”, according to the hearing document.
It also said that there was “no evidence of patient harm” and that she had an otherwise “unblemished record”, as well as acknowledging that she has undertaken a “significant amount of relevant” continuing professional development (CPD) and shadowed other superintendents.
Ms Esulaja’s representative pointed out that the online pharmacy “only dispensed between 50-70 prescriptions per week” and that these “were not huge numbers of addictive drugs going out of the pharmacy”, according to the hearing document.
They added that this “was not among the most serious of cases of failings in an online pharmacy context”.
Ms Esulaja did not financially gain from her misconduct “whatsoever” had “absolutely no experience” as a superintendent, they said.
“While this could be held against her, it also afforded her the opportunity to demonstrate, as she had done, that she had undertaken substantial remediation,” they added.
Among “a number of positive testimonials” were comments from colleagues and employers that Ms Esulaja is “a reliable and hardworking individual who always puts her patients first” and that she is “clinically sound and highly professional” with an “attention to detail”.
Ms Esulaja’s representative stated that she gave oral evidence including “answering difficult questions in which she had shown that she was able to reflect openly and honestly in relation to her previous failings”.
She “had shown insight including looking at her own personal failings, for example a wish to assist family members, and genuine remorse”, they added.
Ms Esulaja was able to “understand the consequences of her conduct” and “had explained that she now appreciates the merits of face-to-face consultations and considers that even phone consultations are less helpful”, according to the hearing document.
“When her husband suggested they should offer an online prescribing service in their new business she had refused,” it said.
Ms Esulaja is now running a high street pharmacy in Sidcup with her husband, for which she became superintendent in March 2023, according to the document.
“Known to be open to abuse”
But the hearing document stressed that Ms Esulaja was “responsible” for the overall management of the pharmacy as the superintendent.
It added that the medicines involved were “high risk, prone to addiction and known to be open to abuse.”
And it said that new distance-selling guidance had been issued in April 2019 so Ms Esulaja had “ample time to familiarise herself” with it.
The committee also found that Ms Esulaja could have continued her “misconduct” and that it was only noticed because of the regulator’s unannounced inspection.
“Risk to patients or the public”
The GPhC concluded that Ms Esulaja currently “presents an actual or potential risk to patients or to the public” and that her “fitness to practise is impaired by reason of [her] misconduct.”
The committee considered taking no action or imposing a warning but decided neither outcome would protect the public or restore and maintain “confidence in the profession and the regulatory process”, according to the hearing document.
“Both would be insufficient to reflect the seriousness of the misconduct”, it said.
The committee decided to suspend Ms Esulaja from the register and that a period of suspension of nine months is “proportionate” to “mark the seriousness of its findings”.
The decision will not take effect until May 9 or once any appeal is concluded, but the regulator imposed an interim suspension to take effect immediately until then.
Read the full determination here