CD Register Falsifications Lead to 12-Month Conditions: Pharmacy Technician Sanctioned After Suspension Review

Date of Decision: August 15, 2025

Registrant's Role: Pharmacy technician

Allegations:

• 14 allegations of falsified controlled drug register entries
• Failing to have any amendments to CD registers witnessed by another staff member.

Outcome: 12-month Conditions of Practice order on review

GPhC Standards Breached:

• Standard 2 – Work in partnership with others.
• Standard 3 – Communicate effectively.
• Standard 5 – Use your professional judgement.
• Standard 8 – Speak up when you have concerns or when things go wrong.

Case Summary

Allegations
This review concerned a sustained pattern of falsifying and retrospectively altering Controlled Drug (CD) registers across multiple Schedule 2 medicines—opioids (morphine sulfate MST 10mg, 15mg, 60mg; oxycodone as Longtec/Shortec) and stimulants (methylphenidate as Xaggitin XL, Medikinet/Tranquilyn)—with repeated “balance checks” certified as correct immediately after inaccurate entries. The conduct included invented stock receipts (e.g., +132 MST 10mg; +120 MST 10mg; +48 MST 10mg; +56 MST 15mg), fabricated supplies and returns (Longtec to a patient who had not received it since March 2021; Xaggitin XL to a patient who had moved), and back-calculated dispensing quantities (Shortec 5mg “21 not 42”) to force the running balance to match the physical count. Several amendments were made without a witness, contrary to expected CD governance, and implausible pack sizes were used (e.g., adding 56 MST 15mg when the pack size was 60), all pointing to register manipulation to make figures “fit” rather than to accurately record lawful receipt and supply.

Findings
At the principal hearing in May 2025, the registrant admitted Allegations 1–15 and accepted that the entries were misleading, though initially disputed dishonesty; dishonesty was found proved on Allegation 16 using the standard test. There was no suggestion of personal financial gain, but the volume, duration and pattern of behaviour—persisting until discrepancies were uncovered—amounted to serious misconduct undermining the integrity of the CD register, with attendant risks: incorrect patient supplies and potential diversion outside the lawful supply chain. The committee expressly found breaches of Standards 2, 3, 5 and 8 of the GPhC Standards for Pharmacy Professionals, noting that failing to have amendments witnessed compounded concealment. As the panel put it:

“Dishonesty is a serious departure from the expected standard and would be regarded as deplorable by other pharmacist.”

The review panel (15 August 2025) acknowledged positive steps since suspension: updated reflections and CPD in ethics and fitness to practise. However, it was troubled that, when accepting a receptionist role in a GP surgery, the registrant did not disclose the suspension during interview—suggesting ongoing risk of reverting to concealment under pressure. The panel concluded that, despite some progress, full remediation had not yet been demonstrated within a pharmacy setting and the risk of repetition remained.

GPhC Determination on Impairment
Applying Rule 5(2) (mirroring Grant) and relevant authorities, the panel found current impairment on both public protection and public interest grounds. The conduct presented an actual/potential risk to patients and the public; brought the profession into disrepute; breached fundamental professional principles; and involved dishonesty with a risk of future dishonesty if similar pressures arose. The panel emphasized that CD registers are fundamental to safe custody and accountability. Errors like fabricating a “missed delivery” without supplier verification should be logged as unresolved discrepancies and escalated to the Accountable Officer rather than “force-balancing” the register. Immediate “correct” balance checks after manipulative entries, brand-switching explanations (e.g., Medikinet/Tranquilyn confusion), and un-witnessed amendments collectively pointed to attitudinal risks that had not been fully addressed.

Sanction
At the principal hearing, conditions were initially rejected and a three-month suspension was imposed to mark seriousness while allowing time for remediation. On review, with additional reflection and CPD evidence, the panel concluded public protection and the wider public interest could now be achieved through a structured return under conditions rather than continued suspension. A 12-month Conditions of Practice order was directed (to commence on expiry of the existing suspension), with key requirements: (1) notify the GPhC of all employment details and any changes; (2) proactively inform (and evidence informing) employers, superintendents, RPs, line managers, locum agencies and the Accountable Officer for CDs of the conditions—prospective employers must be notified at application; (3) secure GPhC-approved workplace supervision by a registered pharmacist or pharmacy technician, remain under remote supervision, and consent to information-sharing; and (4) four-monthly supervisor reports addressing honesty, probity, candour and transparency. A further review will occur near the end of the 12 months. The decision will not take effect until 12 September 2025 (or the conclusion of any appeal).

Key Learning Points for Pharmacy Professionals
• CD register integrity is non-negotiable. Entries must be contemporaneous, accurate and verifiable against prescriptions, invoices and delivery notes. Never add “ghost stock” to make a balance fit or create fictitious supplies/returns to reconcile counts. If the balance does not reconcile, record the discrepancy and escalate—do not “correct” the register.
• Witnessing matters. Amendments to CD registers should be witnessed by another competent staff member and clearly reasoned. The lack of a witness in this case was viewed as additional concealment.
• Know your products and pack sizes. Implausible quantities (e.g., 56 MST 15mg when packs are 60) are red flags. Be mindful of brand-specific products (Medikinet/Tranquilyn, Longtec/Shortec, Xaggitin XL) and ensure supplies are recorded under the correct brand/strength and to the correct patient.
• “Speak up” is active, not passive. If overwhelmed or systems are weak (e.g., no delegated CD lead), escalate early to the RP, superintendent, or AO. Use incident systems and SOPs for unresolved discrepancies rather than self-directed register manipulation.
• Candour extends beyond the pharmacy. Non-disclosure of regulatory restrictions to a healthcare employer undermined confidence in the registrant’s progress. Be transparent about restrictions/conditions in all healthcare roles, even non-registrant posts, and seek support promptly when under pressure.
• Remediation must be demonstrable in practice. Courses and written reflections help, but panels also look for evidence that learning has been applied in real-world pharmacy contexts—supervised practice, feedback, and sustained, witnessed compliance with CD governance.

Overall, the case underlines that falsifying any element of the CD supply chain—even with the intention of “tidying up” or reducing pressure—is dishonest, unsafe, and seriously undermines public trust. A structured, transparent return with robust supervision and regular reporting can be an appropriate route back to safe practice, but only where insight, candour and reliable day-to-day behaviours are convincingly demonstrated over time.

Original Case Document

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