Pharmacist Given 12-Month Conditional Registration After Multiple Dispensing Errors and Patient Harm

The registrant admitted to a series of six dispensing errors between 2018 and 2019 while working as a pharmacist and pharmacy owner. The errors included:

• Supplying Bisoprolol instead of Bendroflumethiazide
• Dispensing Amiodarone instead of Amisulpride
• Giving Rosuvastatin instead of Rivaroxaban
• Labelling Amoxicillin with the incorrect dose for a child
• Supplying Metoprolol instead of Mirtazapine, which led to hospitalisation
• Giving Amitriptyline instead of Azathioprine, causing symptoms including shaking, asthma worsening, and liver pain

Most incidents involved trainees or students dispensing unsupervised, and the pharmacist failing to perform final checks.

In one case, a patient was hospitalised after taking the wrong medication for 15 days. Another patient experienced moderate harm, including heightened asthma and liver pain.

Findings

The GPhC panel concluded that:

• The pharmacist’s failings were serious and repeated.
• He showed limited insight, often blaming staff rather than taking full responsibility.
• Errors continued even after GPhC advice and a formal warning.
• The misconduct posed a risk to patient safety and undermined public trust.

A direct quote from the ruling stated:

“The registrant had demonstrated limited insight into his failings… the dispensing errors continued despite advice and a warning from the GPhC.”

While the pharmacist acknowledged the failings, his reflections were deemed insufficient, and he had not shown how his learning would be applied in practice.

GPhC Determination on Impairment

The Committee found the registrant’s fitness to practise was currently impaired, due to:

• Actual harm caused to patients
• Failure to learn from past regulatory interventions
• Lack of sufficient insight or remediation
• Ongoing risk to the public and the need to uphold professional standards

The committee did not accept retirement as a mitigating factor, noting that fitness to practise decisions must be based on whether a pharmacist is safe to practise without restriction, regardless of retirement intentions.

Sanction

A 12-month conditional registration was imposed, including the following conditions:

• Cannot work as a Responsible Pharmacist
• Cannot carry out final accuracy checks for POMs
• Must inform the GPhC of all roles and provide contact details of employers/supervisors
• Must notify all employers, agencies, and relevant NHS bodies of the conditions
• Must provide reflections on his practice and submit an employer reference at the review hearing

The committee said:

“Conditions are proportionate and sufficient to protect the public and uphold public confidence.”

A review hearing is scheduled at the end of the 12-month period to assess progress.

Key Learning Points for Pharmacy Professionals

1. Final accuracy checks must never be skipped – Especially with high-risk or lookalike medicines.
2. Supervision of trainees is a legal and professional obligation – Errors caused by students reflect on the pharmacist.
3. Insight and remediation must go beyond apologies – Regulators expect structured learning and implementation.
4. Warnings and advice must be taken seriously – Repeating mistakes after regulatory intervention worsens outcomes.
5. Leadership includes accountability – As a pharmacy owner and superintendent, the registrant was expected to set standards.

Conclusion

This case highlights the serious consequences of repeated dispensing errors, particularly when combined with insufficient supervision and poor insight. Despite a long career, the registrant’s failure to learn from previous warnings and the harm caused to patients warranted significant regulatory intervention. The 12-month conditional registration reflects the seriousness of the failings while giving the pharmacist an opportunity to demonstrate safe practice through supervision and reflection.