Allcures Pharmacist Warned for Controlled Drug Recording Breaches and Dispensing Error Involving Medikinet and Tranquilyn

Allegations
This case concerned a registered pharmacist acting as the Responsible Pharmacist at Allcures Pharmacy in July 2024. The allegation centred on the dispensing of a controlled drug — Medikinet 5mg tablets (methylphenidate hydrochloride) — for a patient. Instead of supplying the full quantity prescribed, the pharmacist dispensed a mixture of Medikinet 5mg and Tranquilyn 5mg (another methylphenidate brand) without any authorised Serious Shortage Protocol (SSP) in place. An SSP is the only lawful mechanism by which a substitution of medication, especially for a controlled drug, can be made without a prescriber’s intervention.

Alongside the dispensing error, the pharmacist was alleged to have failed to maintain accurate entries in the Controlled Drug (CD) register — a legal requirement under the Misuse of Drugs Regulations 2001. The situation was further aggravated by the retrospective alteration of CD register entries relating to Tranquilyn 5mg tablets. Such retrospective amendments are a red flag in the context of CD governance, as they raise concerns about potential concealment of errors or irregularities.

Findings
The General Pharmaceutical Council’s Investigating Committee found that the registrant’s actions constituted breaches of multiple professional standards. Dispensing the mixed medication without a valid SSP risked patient safety and undermined the principle of providing person-centred care (Standard 1). The alteration of the CD register — especially after the fact — called into question the registrant’s honesty and integrity, engaging Standards 5 (professional judgement), 6 (professional behaviour), and 8 (speaking up when things go wrong).