Pharmacist Given 12-Month Conditional Registration for Failing to Manage Controlled Drugs Safely

Over several inspections between 2018 and 2019, GPhC inspectors found that the registrant:

• Was unable to produce up-to-date CD registers, particularly for medicines including MST, Zomorph, Concerta, Fentanyl, and others.
• Kept controlled drug records, emergency supply logs, and private prescription records at home, instead of at the pharmacy.
• Stored CDs improperly, including morphine found in a consultation room rather than the CD cabinet.
• Continued these unsafe practices despite repeated interventions from the GPhC and the police.

The registrant admitted to all allegations and stated that the issues arose after both full-time dispensers left.

Findings

The GPhC Fitness to Practise Committee concluded that:

• The registrant breached multiple key GPhC standards and demonstrated serious professional misconduct.
• There was a risk of harm to the public, particularly from CD mismanagement and poor record-keeping.
• There were clear risks of diversion of CDs and breaches of patient confidentiality due to off-site storage of sensitive records.

A key quote from the determination:

“This behaviour was deplorable. Fellow pharmacy professionals would find it so, as would members of the public, and it met the test for serious misconduct.”

Despite some remedial steps and CPD, the panel noted:

• The registrant’s remediation was limited and began only after suspension.
• SOPs were still not fully reviewed (some referred to care homes), and no full plan for staff was in place.
• There was insufficient evidence of insight from colleagues or mentors.

GPhC Determination on Impairment

The committee found that the registrant’s fitness to practise was impaired, based on:

• The ongoing risk of repetition given insufficient remediation.
• The importance of public confidence in the regulation of Controlled Drugs.
• The expectation that pharmacists show leadership and professional responsibility, which the registrant had failed to do.

The Committee ruled that conditions were preferable to suspension because:

• The registrant had expressed a genuine willingness to comply.
• The misconduct, though serious, occurred in an otherwise unblemished 30-year career.
• There was potential for successful remediation under strict supervision.

Sanction

The committee imposed a 12-month conditional registration, requiring the registrant to:

• Work only under approved supervision.
• Develop a personal development plan with a mentor.
• Submit regular reports and carry out CD audits every two months.
• Refrain from acting as a Responsible Pharmacist or Superintendent.
• Limit practice to 4 days a week, with a full-time pharmacist responsible for CD governance.

An interim order applying these same conditions was also imposed to ensure public protection immediately.

Key Learning Points for Pharmacy Professionals

1. CD management is non-negotiable – Poor governance or documentation around CDs poses a serious risk and leads to regulatory action.
2. Keeping pharmacy records at home is a breach of confidentiality – All documentation must be stored securely on-site.
3. Remediation must be proactive and thorough – Waiting until disciplinary action starts is not enough.
4. Leadership means accountability – Pharmacists, especially in senior roles, are expected to uphold standards even under pressure.
5. Conditions are an opportunity for reform, not a soft option – Strict supervision, training, and audits form a second chance that must be taken seriously.

Conclusion

This case underscores the critical importance of Controlled Drug governance, record-keeping, and leadership responsibilities in pharmacy practice. Although the registrant had no prior fitness to practise history, the GPhC determined that the risk to public safety and the profession’s reputation justified 12 months of strict conditional practice. The case is a strong reminder that standards must be maintained at all times—not just when under scrutiny.