Locum Pharmacist Struck Off After Dangerous Methadone Dispensing Error and Dishonesty

Date of Decision: May 13, 2019

Registrant's Role: Pharmacist

Allegations:

Supplied methadone to a patient without a prescription or clinical justification
Failed to provide clinical advice or seek emergency medical treatment after the error
Attempted to conceal the error and provided dishonest accounts to colleagues
Failed to declare a prior criminal conviction to the GPhC
Engaged in dishonest conduct by concealing the conviction during applications for registration

Outcome: Removal from the register

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 2 – Work in partnership with others
Standard 3 – Communicate effectively
Standard 5 – Use professional judgement
Standard 6 – Behave in a professional manner
Standard 8 – Speak up when things go wrong
Standard 9 – Demonstrate leadership

Case Summary

Allegations

The case centres on a serious dispensing error made by the registrant, a locum pharmacist, while working at a community pharmacy. On 23 September 2017, the registrant inadvertently supplied methadone—an opioid substitution therapy medication—to Patient A, who had only attended the pharmacy for treatment of a tickly cough. Critically, Patient A had neither been prescribed methadone nor was there any clinical need for it.

The error occurred when the registrant, acting as the Responsible Pharmacist, confused Patient A with Patient B, who was the actual recipient of the methadone. The registrant supervised Patient A consuming one dose of methadone on-site and provided another bottle for home consumption.

The situation escalated when the registrant failed to inform Patient A of the error upon realizing the mistake. Instead, he retrieved the second bottle from her home without disclosing the potential danger and did not advise her to seek immediate medical help. As a result, Patient A suffered adverse effects, later requiring hospital admission for 24 hours.

Rather than report the incident transparently, the registrant attempted to conceal it. He falsely told colleagues that the methadone had been spilled and even instructed them not to disclose the true nature of the event. When questioned by the pharmacy’s Regional Quality Manager, he continued to maintain this false account.

Additionally, the registrant failed to disclose a criminal conviction when applying for re-registration with the GPhC. This conviction dated back to 2011 and was relevant to previous regulatory concerns. The registrant had been struck off by the RPSGB (the predecessor of the GPhC) and only regained registration after misleading the Council by omitting a subsequent conviction.

Findings

The Committee found the allegations to be fully admitted and proven. The registrant’s conduct was described as a sustained sequence of dishonest acts. His failure to disclose a potentially life-threatening error and attempts to mislead both colleagues and the regulator demonstrated serious professional failings.

The methadone incident was particularly concerning, as the registrant placed a patient at risk of significant harm. Not only was the medication wrongly dispensed, but there was a complete absence of safety netting—no clinical advice was given, nor was any emergency support arranged. Patient A’s hospitalisation underscored the gravity of the situation.

The Committee highlighted that the registrant had multiple opportunities to correct his error but instead chose concealment. His conduct extended beyond a single moment of poor judgement and reflected a deeper, more concerning pattern of behaviour.

GPhC Determination on Impairment

The Committee concluded that the registrant’s fitness to practise was currently impaired by reason of misconduct. It cited all four criteria under Rule 5(2) of the Fitness to Practise Rules, noting:

A clear actual risk of harm to a patient occurred
The registrant’s actions had brought the pharmacy profession into disrepute
Fundamental principles of honesty, integrity, and duty of candour were breached
The registrant’s integrity could no longer be relied upon

The registrant’s lack of insight, failure to show remediation, and repeated dishonesty were key in determining ongoing impairment. Although he admitted the allegations, the Committee found that his actions “would undoubtedly undermine public confidence in the profession.”

“He has a criminal conviction… He failed to notify the Council… He has repeatedly sought to cover up his dispensing error.”

Sanction

After considering the full range of sanctions, the Committee determined that removal from the register was the only appropriate and proportionate response. Suspension or conditions were deemed insufficient due to the seriousness and persistence of the registrant’s misconduct.

The Committee emphasised that his behaviour—particularly the deliberate deception of colleagues and the failure to act in a patient’s best interests—was fundamentally incompatible with professional registration.

Despite the registrant’s stated intention not to return to practice, the Committee found it essential to act in the interest of public safety and to uphold confidence in the pharmacy profession. Consequently, the Committee directed the GPhC to remove the registrant from the register and imposed an interim suspension to cover the appeal period.

Key Learning Points for Pharmacy Professionals

Duty of Candour is Non-Negotiable: Pharmacy professionals must be honest when things go wrong. Attempting to conceal errors undermines patient safety and erodes trust.
Responsibility in Controlled Drug Dispensing: Methadone is a high-risk medicine. This case underscores the critical importance of verifying patient identity, prescription accuracy, and engaging in clear communication during supervised consumption.
Responding to Errors with Integrity: Mistakes may happen, but how professionals respond is pivotal. Immediate disclosure and arranging appropriate care are not just best practice—they are professional obligations.
The Weight of Dishonesty: Misleading colleagues, falsifying records, and failing to declare past convictions each represent serious breaches of professional trust. The registrant’s behaviour was not just a lapse—it was a sustained breach of ethical standards.
Fit to Practise is About Character: This case reaffirms that fitness to practise is as much about honesty and judgement as it is about clinical competence.

In sum, this case serves as a stark reminder that integrity and patient-centred care are foundational to pharmacy practice. Regulatory bodies will take robust action to protect the public and uphold the profession when these principles are compromised.

Original Case Document

The full determination transcript is available to logged in users.