Pharmacist Receives Conditional Registration After Multiple Controlled Drug Handling Errors
Date of Decision: February 12, 2019
Registrant's Role: Pharmacist
Allegations:
- Made non-chronological entries in the CD register.
- Failed to seal a dosette box leading to Morphine Sulphate Tablets being misplaced.
- Incorrectly recorded or omitted CD entries.
- Advised dispensing Temazepam without a valid prescription.
- Provided misleading information during employment applications.
- Failed to comply with SOPs, storage, and labelling procedures.
- Dishonestly omitted prior suspension and employment history from CV.
Outcome: Twelve-month conditional registration order with review
GPhC Standards Breached:
- Standard 1.1 – Make sure the services you provide are safe and of acceptable quality.
- Standard 1.6 – Do your best to provide medicines and other professional services safely and when patients need them.
- Standard 5.1 – Recognise the limits of your professional competence.
- Standard 5.2 – Maintain and improve the quality of your practice by keeping your knowledge and skills up to date.
- Standard 5.3 – Apply your knowledge and skills appropriately to your practice.
- Standard 5.4 – Learn from assessments, appraisals and reviews of your performance and undertake further education if necessary.
- Standard 6.5 – Meet accepted standards of personal and professional conduct.
- Standard 6.6 – Comply with legal and professional requirements and accepted guidance.
- Standard 7.1 – Practise only if you are fit to do so.
- Standard 7.4 – Take responsibility for all work you do or are responsible for.
- Standard 7.6 – Be satisfied that appropriate SOPs are in place and are being followed.
- Standard 7.7 – Ensure your workload and conditions do not present risks to care or safety.
Case Summary
Allegations:
This case centers on a pharmacist whose practice was marred by multiple incidents involving poor controlled drug (CD) record-keeping, breaches in standard operating procedures (SOPs), and a serious lapse in judgment involving the suggestion to dispense Temazepam without a valid prescription. These events occurred over several months in 2016, across multiple pharmacy settings. The registrant’s errors raised significant concerns about patient safety, professional reliability, and public trust.
The General Pharmaceutical Council (GPhC) alleged a range of misconduct including inaccurate and non-chronological CD entries, dispensing errors, failure to follow SOPs, and misrepresenting his employment history to a prospective employer. Some allegations also involved dishonesty, though not all were found proven.
Continue Reading the Full Case
Create a free account or log in to access the complete case summary.
- Full allegations considered by the GPhC
- Panel findings and reasoning
- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
View the Full Determination Document
The original determination transcript is available to registered users.
- Download the official GPhC determination
- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
- Details of the pharmacy professionals involved