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.

Findings:

The Fitness to Practise Committee found multiple allegations proven, particularly those involving mishandling of controlled drugs. Specific proven issues included:

• Failing to adequately seal a dosette box, leading to misplaced Morphine Sulphate Tablets (MST), which had to be retrieved.
• Advising a colleague to dispense Temazepam without a valid prescription.
• Inaccurate CD record entries, including writing two conflicting stock numbers without a clear explanatory footnote, which obscured the actual CD stock level.
• Failure to store patient prescriptions in accordance with the pharmacy’s SOP.
• Admitted dispensing MST quantities that deviated from the prescribed amount on two occasions.

Notably, the Committee accepted that while some allegations were not proven—particularly those involving dishonesty about prior employment—others showed a concerning pattern of poor practice. The registrant’s failure to report a suspension and exclusion of certain employment history from his CV were not deemed dishonest due to lack of duty or intent to deceive under the circumstances.

GPhC Determination on Impairment:

The Committee determined that the registrant’s fitness to practise was impaired by reason of misconduct. The findings pointed to sustained failures in basic pharmacy practices, particularly in handling and recording of CDs—substances with high potential for abuse and associated legal scrutiny.

These failings raised concerns over patient safety, professional integrity, and public trust. The panel applied the legal standard for misconduct and concluded that the registrant’s conduct had breached multiple core GPhC standards. The pharmacist’s inability to explain a decision to dispense against a suspicious prescription, limited current knowledge of CD legislation, and insufficient insight further supported this conclusion.

The Committee noted:

“Multiple failures in the basic duties of a pharmacist in respect of the control and supply of controlled drugs over the period of at least a year is sufficiently serious to constitute misconduct.”

Although the registrant demonstrated some insight and acknowledged a previous “cavalier attitude,” he had not yet fully internalized the gravity of his errors or evidenced how he would avoid recurrence, especially under stress. His statement, “I have not been stressed at all since I walked away from pharmacy,” indicated a lack of real-world test for his ability to cope under pressure.

Sanction:

To safeguard public protection and restore confidence in the pharmacy profession, the Committee imposed a twelve-month conditional registration order with a review. It deemed this proportionate, considering that the misconduct was serious but remediable, and the registrant had shown some insight and remorse.

Conditions included:

• Completion of a return-to-practice course.
• Ongoing remote supervision by a registered pharmacy professional.
• Quarterly audits and supervisor reports focused on CD handling.
• Restrictions on working as a sole or superintendent pharmacist.
• Maintenance of a reflective diary to support further development.

These steps aimed to facilitate safe re-entry into practice while ensuring close monitoring and remediation.

An interim conditions order in identical terms was also imposed to protect the public pending full implementation of the substantive order.

Key Learning Points for Pharmacy Professionals:

1. Controlled Drug Protocols Are Non-Negotiable: Pharmacists must demonstrate meticulous care with CD handling, including accurate record-keeping, compliance with SOPs, and proper storage. Missteps—even if well-intentioned—can seriously endanger patients and breach legal requirements.
2. Dispensing Without a Prescription Is a Grave Breach: Even in situations of patient need or operational stress, medicines—especially controlled substances like Temazepam—must not be supplied without a valid prescription. No exceptions exist for such conduct.
3. Transparency with Employers: While not every prior employment detail may be necessary on a CV, transparency regarding suspensions or serious concerns—especially those involving regulatory bodies—is crucial to maintain trust and integrity.
4. Professional Insight and Remediation: Insight is a cornerstone of safe pharmacy practice. Pharmacists must understand the impact of their actions, recognize deficiencies, and take proactive steps to address them, including continuous education.
5. Return to Practice Is a Structured Process: Professionals returning after extended absence or fitness to practise issues should expect to undergo formal assessments, training, and supervision. Engaging willingly with these requirements can support successful reintegration.

This case serves as a robust reminder that professionalism, accountability, and patient safety are foundational expectations in pharmacy practice. While rehabilitation is possible, it must be earned through sustained, demonstrable effort and a commitment to high standards.

Original Case Document

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