Dishonest Morphine Mismanagement: Pharmacist Suspended for Concealing Controlled Drug Destruction Error
Date of Decision: March 19, 2019
Registrant's Role: Pharmacist
Allegations:
- Failed to report the accidental destruction of a box of 60 x 5mg Morphine Sulphate Tablets (MST) to the Superintendent Pharmacist.
- Failed to enter the receipt of a replacement box of MST into the controlled drug register.
- Engaged in dishonest conduct to conceal the destruction and create a false appearance of register accuracy.
- Made dishonest statements in July and August 2017 denying responsibility for the destruction and ordering of MST.
- Attempted to shift blame onto colleagues by suggesting they might have destroyed the MST.
Outcome: 3-month suspension from the register
GPhC Standards Breached:
- Standard 1.8 – Keep full and accurate records
- Standard 6.1 – Act with honesty and integrity
- Standard 6.5 – Meet accepted standards of personal and professional conduct
- Standard 6.6 – Comply with legal and professional requirements
- Standard 6 (2017) – Behave in a professional manner (including honesty and integrity)
- Standard 8 (2017) – Be open and honest when things go wrong
Case Summary
Allegations
This case centers on a pharmacist who, while employed as a Branch Manager, was found to have engaged in a series of dishonest acts concerning controlled drug (CD) management. The core incident involved the unintentional destruction of a box of 60 Morphine Sulphate Tablets (MST) 5mg, a Schedule 2 controlled drug, during a batch disposal of returned patient medicines. Upon noticing the discrepancy during a stock check, the pharmacist ordered a replacement box but deliberately failed to enter the transaction into the CD register to maintain the appearance of stock balance.
Instead of reporting the error to the Superintendent Pharmacist, as required by standard protocols for CD discrepancies, the registrant concealed the issue. More troublingly, in 2017, during internal investigations, the pharmacist made dishonest statements, both orally and in writing, denying any knowledge of the destruction or replacement of the MST. The registrant even suggested that colleagues may have been responsible, thereby attempting to deflect accountability and implicate innocent professionals.
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