Superintendent Pharmacist Suspended for Inappropriate and Excessive OTC Sales of Codeine Linctus to Opioid Addicts
Date of Decision: January 30, 2019
Registrant's Role: Pharmacist
Allegations:
- Inappropriate supply of codeine linctus between January 2012 and May 2018.
- Supplied for unlicensed purposes.
- Supplied to patients in managed addiction programmes without consulting their prescriber.
- Failed to consider:
- Volume and frequency of purchases.
- Misuse or addiction potential.
- Possible codeine dependency.
- Adverse health and wellbeing effects.
Outcome: 12-month suspension from the Register
GPhC Standards Breached:
- Standard 1 – Provide person-centred care: Failed to ensure safe and informed patient care.
- Standard 2 – Work in partnership with others: Did not engage with prescribers or safeguarding services.
- Standard 5 – Use professional judgement: Did not appropriately assess medication suitability.
- Standard 6.6 – Comply with legal and professional requirements: Breached legal standards for medicine supply.
- Standard 7.4 – Take responsibility for all work: Did not ensure responsible supply practices.
- Standard 1.1 – Ensure safe, quality services: Supply endangered vulnerable patients.
- Standard 1.2 – Protect wellbeing: Placed addicts at risk.
- Standard 1.3 – Promote health: Undermined patient health by fueling dependency.
- Standard 1.4 – Assess needs appropriately: Did not assess or record rationale for supply.
- Standard 1.5 – Refer appropriately: Failed to refer addicted patients to medical professionals.
- Standard 1.6 – Provide timely, safe medicines: Supplied large quantities without proper checks.
- Standard 2.1 – Act in best interest: Acted contrary to patient welfare.
- Standard 2.2 – Avoid conflicts of interest: Let habitual practice and profit compromise judgement.
Case Summary
Allegations
The registrant, a superintendent and responsible pharmacist, was found to have supplied excessive quantities of codeine linctus—a Pharmacy (P) medicine—to patients between January 2012 and May 2018, often in inappropriate and unsafe circumstances. Key issues included supplying it for non-licensed purposes (primarily for its sedative or addictive properties rather than as a short-term cough suppressant), supplying it to individuals in managed addiction programmes without consulting prescribers, and failing to adequately consider the implications of codeine misuse, addiction, or potential harm.
The concern initially arose from an anonymous complaint in March 2018. During a subsequent inspection, 40 bottles of codeine linctus were discovered stored under the pharmacy counter—well beyond the norm for routine pharmacy operations. The inspector observed a total stock of 10.2 litres during the visit, with stock levels suggesting significant recent sales activity.
Sales records were largely absent, which is not uncommon for P medicines, but troubling in context. The registrant admitted selling to a core group of five or six known addicts, describing his judgment process as ad hoc. He sometimes refused sales to those he deemed “too young” or “vulnerable,” but made no consistent or documented assessments. He conceded: “once you are the boss, if you have a bad habit it is likely to continue … it became a habit in the Pharmacy … I slipped into a dangerous practice.”
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- 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
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- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
- Details of the pharmacy professionals involved