Dear Mr Parsley,

Thank you for your Regulation 28 report of 31st January 2025 sent to the Secretary of State about the death of Ms Kim Robinson. I am replying as the Minister with responsibility for medicine regulation and prescribing.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Robinson’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter.

The key concern raised by both yourself and the online prescriber was that in consideration of this tragic case, the online prescription service needs to be reviewed. The online GP highlighted the following suggested changes:

• There is a need for online prescribers to be able to access a patient’s records. These records could be attached to the consultation for review by the prescriber.
• All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner.
• Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
• All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
• Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.

In preparing this response, my officials have made enquiries with the General Pharmaceutical Council (GPhC) to ensure we adequately address your concerns. The GPhC has provided a substantial response, which I will outline below, and I have also been advised that the organisation has contacted your office to obtain further details, in line with the GPhC’s policy to investigate any case where death of significant harm has been caused.

I understand the concerns raised by both you and online prescriber regarding online prescribing practices.

When used appropriately, online prescribing provides a valuable route for patients to access their prescription medicines which takes pressure off GP practices.

Prescribers, whether working for the NHS or privately, in-person or remotely, are accountable for their prescribing decisions. They are expected to take account of appropriate national guidance. Prescribers should work with their patient and decide on the best course of treatment, with the provision of the most clinically appropriate care for the patient always being the primary consideration.

In addition to the duty of the prescriber, patients themselves must be honest when providing information to an online prescriber so that they receive advice and medicines which are appropriate for them and so that risks can be managed. As has been highlighted in this very sad case, prescribers need full information to be able to prescribe safely. Where relevant, the General Pharmaceutical Council (GPhC) and other professional regulators, Care Quality Commission (CQC) and the Medicines and Healthcare products Regulatory Agency (MHRA) have the powers to investigate and take action against prescribers, products and suppliers who do not comply with legislation and national guidance. As previously mentioned, I approached the GPhC who advised that at the date of death, 12th May 2024, their March 2022 ‘Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet’ was in place - (a copy of which I have included with my response). Whilst propranolol was not referred to as an example in this guidance, ‘the GPhC considers it to fit within the category of requiring additional safeguards. Relevant to the concern you raise regarding access to patient records, and patient consent to share the details of their prescriptions with their current GP or regular practitioner, the March 2022 guidance sets out the precautions to put in place if medicines requiring additional safeguards are to be supplied online. These include but are not limited to assuring that the person has provided the contact details of their regular prescriber, such as their GP, and their consent to contact them about the prescription; and that the prescriber will proactively share all relevant information about the prescription with other health professionals involved in the care of the person (for example their GP). The guidance states that for medicines which are liable to abuse, overuse or misuse, or when there is a risk of addiction and ongoing monitoring is important, the prescriber should contact the person’s regular prescriber, who should confirm that the prescription is appropriate for the person and that appropriate monitoring is in place. If there are circumstances where the person does not have a regular prescriber such as a GP, or if there is no consent to share information,

the prescriber must then decide whether or not to prescribe. They will need to think about the person’s best interests and make a risk-based assessment about whether they can prescribe safely, taking into account whether the person would be at risk of death or serious harm if they were also getting medicines from other sources. The prescriber must make a clear record setting out their justification for prescribing, or not prescribing. In your report you suggest that all consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” On this point, the GPhC expects pharmacies to carry out a risk assessment for every part of the service they provide. If an appropriate organisation stated that this question should be included, then the GPhC would monitor this through its inspection processes. Relevant to your concern that ‘prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies’. The responsibility for prescribing rests with the prescriber who has clinical responsibility for that particular aspect of a patient’s care. Issuing shorter prescriptions could give the prescriber the opportunity to review the patient’s medicines, which is important for some groups of patients and may therefore be particularly appropriate in some cases. The service provider, whether NHS commissioner or private sector provider has a responsibility to ensure that adequate controls are in place, and they may also issue advice to prescribers about the length of time for which prescriptions should be issued. Further to the above, the GPhC has advised that they have recently updated their distance selling guidance (i.e. March 2022 guidance referenced above) in February 2025. The updated guidance can be found here: Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet. The guidance was updated in response to concerns relating to unsafe prescribing and supply of medicines online and includes strengthened safeguards designed to prevent people from receiving medicines that are not clinically appropriate for them and may cause them harm. Specifically, the February 2025 guidance sets out what to include in a risk assessment when prescribing services are involved, this includes considering how the diverse needs of people using pharmacy services are identified, and how staff get users’ valid consent (for example, how staff assess the mental capacity of users). The February 2025 guidance states that “The risk assessment should cover the whole service, including the medicines and treatments which are provided”. This guidance updates on medicines that should not be supplied without further safeguards. This includes medicines which have a higher risk of fatality or serious harm if taken in overdose, and amitriptyline, propranolol, colchicine and carbamazepine are pulled out as examples. The GPhC have also indicated that they would consider propranolol to fall under the ‘medicines liable to misuse’ and ‘medicines and long-term conditions that require ongoing monitoring or management’ categories in their updated guidance. The February 2025 guidance sets out strengthened safeguards that should be in in place before supplying these types of medicines online. It states that a prescriber should not base prescribing decisions on the information provided in a questionnaire alone. Instead, the prescriber should independently verify the information the person provides, and get the information they need to support their prescribing decisions. This could be through timely two way communication with the person, accessing the person’s clinical records, or contacting the person’s GP, their regular prescriber, or a third-party provider. If the prescriber chooses not to use two-way communication with the person to support their prescribing

decision, they should make a record, specific to the individual person's circumstances, justifying their reasons. If the prescriber cannot independently verify the information the person provides or get the information they need, the person should be directed to an appropriate care provider so that they can be appropriately assessed. Examples include, but are not limited to, an out-of-hours service, a local walk-in centre, or urgent care. It is unclear if the prescriber was a pharmacist, however the GPhC also has practise guidance for pharmacist prescribers which can be found here:

pharmacistprescribers-february-2020.pdf. You may also want to contact the Care Quality Commission (CQC) and the General Medical Council (GMC) for information on the work they are doing to ensure online prescribing is safe. Lastly, I would like to assure you that we are committed to tackling suicide as one the biggest killers in this country. As part of this, the 8,500 new mental health workers we will recruit will be trained to support people at risk to reduce the lives lost to suicide. We are also committed to continuing to deliver the cross-sector Suicide Prevention Strategy for England published in 2023. This identifies a number of groups for tailored or targeted action at a national level, including people who have self-harmed and people in contact with mental health services. I hope this response is helpful. Thank you for bringing these concerns to my attention.