Pharmacist Suspended for Three Months Following Failure to Manage Codeine Linctus Supply Risks

The General Pharmaceutical Council (GPhC) Fitness to Practise Committee reviewed the case of the registrant, the sole owner and responsible pharmacist at F.F. & R. Stevenson Pharmacy, following concerns over the uncontrolled supply of codeine linctus between July 2017 and September 2020.

The allegations were initially reviewed in November 2023, when the committee found that the registrant had:

• Ordered large volumes of codeine linctus without sufficient oversight.
• Supplied up to 2 x 200ml bottles every three days to a known customer, despite signs of misuse.
• Continued to supply another individual weekly despite suspected addiction.
• Failed to establish safeguards, such as monitoring purchases, identifying repeat customers, and refusing supply when appropriate.

As a result, conditions were imposed on the registrant’s registration for 12 months, requiring them to complete training and provide a reflective account demonstrating insight into their misconduct.

Findings

At the review hearing, the committee found that the registrant:

• Did not complete the required training on medicines with potential for misuse.
• Failed to submit a reflective account or peer discussion as required by the previous conditions.
• Expressed no remorse or insight, stating:

“I’ve been giving out medications for many years and I know what I’m doing, except for the one incident that happened.”

Despite being given multiple reminders, the registrant actively refused to engage with the GPhC’s requirements, stating that he “did not see the point” in completing the training.

The panel noted that while the registrant had complied with the restrictions on codeine linctus supply, the refusal to complete training and demonstrate insight undermined confidence in his ability to practise safely in the future.

GPhC Determination on Impairment

The committee ruled that the registrant’s fitness to practise remained impaired, citing:

• A risk of repetition due to their failure to demonstrate insight.
• A lack of engagement with regulatory requirements, showing disregard for public safety and professional standards.
• Damage to public confidence, as continued non-compliance reflected poorly on the pharmacy profession.

Given the registrant’s refusal to engage with previous conditions, the committee concluded that maintaining conditional registration was no longer appropriate.

Sanction

The committee imposed a three-month suspension as the most proportionate sanction, considering:

• The seriousness of the misconduct, which involved sustained failure over three years to manage the risks of supplying codeine linctus.
• The registrant’s continued lack of insight and refusal to engage with the conditions previously imposed.
• The need to protect public confidence in pharmacy regulation.

The committee considered removal but determined that the registrant should be given one final opportunity to remediate.

Additionally, an interim suspension was imposed immediately, preventing the registrant from practising until the full suspension takes effect or any appeal is resolved.

Key Learning Points for Pharmacy Professionals

1. Pharmacists must actively manage the supply of medicines with abuse potential – Simply complying with basic regulations is not enough if patient safety is at risk.
2. Regulatory compliance is mandatory – If conditions are imposed, registrants must engage with the process fully to demonstrate their fitness to practise.
3. Lack of insight leads to serious consequences – Even after complying with restrictions, failure to reflect or take remedial steps can result in suspension.
4. GPhC sanctions escalate if registrants fail to engage – The committee initially imposed conditions, but due to non-compliance, it proceeded to a suspension.
5. Public confidence in pharmacy must be upheld – Even when misconduct relates to a single medication, failing to act responsibly damages the reputation of the entire profession.

Conclusion

This case highlights the importance of regulatory engagement and professional accountability. While the registrant had stopped the inappropriate supply of codeine linctus, their failure to reflect, complete training, or demonstrate insight led to a three-month suspension. The outcome serves as a clear warning that ignoring GPhC requirements will result in escalated sanctions.