Lloydspharmacy Pharmacist Issued Warning for Dispensing Error, Data Misuse, and Improper Staffing Practices

The General Pharmaceutical Council (GPhC) investigated the registrant after Lloyds Pharmacy (now McKesson UK) raised concerns regarding two separate incidents involving professional misconduct.

1. Dispensing Error and Data Misuse

On 5 February 2022, the registrant made a dispensing error involving Physeptone 1mg/ml oral solution (a Schedule 2 Controlled Drug). Instead of following proper procedures:

• The registrant did not report the error, failing to trigger internal learning and accountability.
• He instead retrieved the patient’s home address from another pharmacy’s Patient Medication Record (PMR) system.
• He then visited the patient’s home in person, raising concerns about confidentiality, privacy, and professional boundaries.

2. Improper Staffing and Fraudulent Payment Facilitation

The registrant also:

• Allowed an individual who had previously done work experience to work in the pharmacy for several weeks without arranging formal employment or payment.
• Facilitated payment by falsely signing off another colleague’s unworked overtime, allowing the funds to be redirected to this individual.
• The colleague involved in the overtime fraud was a relative of the individual working informally.

Findings

The GPhC concluded that while there was no evidence of direct harm, the registrant’s actions:

• Put both patients and pharmacy colleagues at risk, particularly in relation to controlled drug handling.
• Undermined public trust in the pharmacy profession through dishonest and non-compliant conduct.
• Reflected a lack of professional boundaries and leadership, particularly in his dual roles of responsible pharmacist and manager.

A direct quote from the ruling emphasised the core issues:

“[The registrant]’s actions exposed both patients and colleagues alike to risk of harm by not performing the adequate clinical checks required to deal with high-risk medications.”

The panel stressed the seriousness of data misuse, poor medicines governance, and the need for ethical staffing practices.

Sanction

The GPhC issued a formal warning, which:

• Will be published on the register for 12 months.
• Acts as a public declaration of serious but remediable professional misconduct.
• Warns that any similar failings in the future will likely result in more severe regulatory action.

The registrant was advised to:

• Always report and document dispensing errors, especially for controlled drugs.
• Respect patient privacy and data protection standards, including not accessing or using information without proper authority.
• Ensure that all individuals working in a pharmacy are appropriately recruited, trained, and paid through formal channels.

Key Learning Points for Pharmacy Professionals

1. Dispensing errors must always be reported – Transparency and incident learning are essential to patient safety.
2. Accessing patient records requires strict justification – Using patient data for unregulated or personal contact is a breach of privacy.
3. Controlled drug incidents carry higher regulatory expectations – These require clinical checks and escalation, not informal resolution.
4. All staff must be formally employed and remunerated properly – Pharmacy teams must operate within lawful employment frameworks.
5. Leadership includes integrity and procedural compliance – Pharmacists must lead by example, even under pressure.

Conclusion

This case highlights how multiple small breaches—when involving patient safety, privacy, and staffing—can amount to significant professional misconduct. The GPhC’s decision to issue a 12-month formal warning serves as a clear message that pharmacists must act with honesty, transparency, and full compliance with both clinical and managerial responsibilities.