GPhC suspends Responsible Pharmacist for 3 months after CD register failures and unsafe reuse of returned medicines

Allegations
This case centres on CD governance and unsafe medicines handling at a community pharmacy where the registrant was the Responsible Pharmacist (RP) and manager. Following an unannounced visit by the Controlled Drugs Liaison Officer on 18 October 2022, CD registers were not on site; they were later retrieved from the registrant’s home. On inspection, CD registers showed no updates since approximately June 2018. Tote boxes containing CDs were stacked in the dispensary, with the CD cabinet full and out-of-date CDs awaiting destruction. Thirty-five CD balance discrepancies were subsequently reported.

In addition, a dispenser (later pharmacy manager) alleged that patient-returned medicines were placed back into stock and that contents of unmarked dosette trays were reused to make new trays during April–August 2022. The registrant denied both allegations. A later inspection in May 2023 found unsealed MDS awaiting accuracy checks, incomplete fridge-temperature monitoring across all fridges, and unclean measuring equipment.

Findings
The registrant admitted particulars 1, 2, 3, 6, 7 and 8. After hearing live evidence, the Committee preferred the witness evidence for particulars 4 and 5, finding them proved on the balance of probabilities. The Committee recognised the registrant’s lack of personal financial motive but noted that, by the registrant’s own account, processes had fallen seriously behind, creating “chaos and confusion” in the dispensary that extended to unsafe reuse of medicines from returns and unlabelled dosette boxes.