Well Pharmacist Removed for Repeated Dispensing of Controlled Drugs Without Prescriptions

Date of Decision: August 19, 2025

Registrant's Role: Pharmacist

Allegations:

Dispensed controlled drugs to three patients without prescriptions over a period of several months.
Self-checked the dispensing of controlled drugs in contravention of protocols.
Instructed dispensers to hand out controlled drugs without appropriate pharmacist supervision.
Failed to report the incidents promptly on the employer's DATIX system despite being requested to do so.

Outcome: Removal from the Register

GPhC Standards Breached:

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

Case Summary

Allegations

This case involved a pharmacist who, over several months between March and October 2020, dispensed controlled drugs (CDs) to three patients—Patients A, B, and C—without the requisite prescriptions. The pharmacist was the responsible pharmacist and Branch Manager at the time. Medications dispensed without prescriptions included high-risk substances such as Buprenorphine, Pregabalin, Transtec patches, Diazepam, Espranor, and Nitrazepam. These are all controlled substances with a significant potential for abuse and serious patient harm.

Allegations also included unsafe practices such as self-checking of CDs—a deviation from standard operating procedures (SOPs)—and instructing or permitting dispensers to supply these CDs to patients without pharmacist oversight. Furthermore, the registrant failed to report the incidents on her employer’s internal DATIX system despite being asked to do so, although she did upload incident forms to the Local Health Board’s reporting system.

Findings

The original Principal Hearing Committee, and subsequent review committees, consistently found that the registrant’s actions amounted to serious misconduct. Her conduct not only breached the legal framework governing the dispensing of CDs but also violated core standards expected of pharmacy professionals. The principal hearing described her actions as:

“A serious failure of clinical judgement… acting illegally, cutting corners on patient safety procedures and dispensing controlled drugs without assuring herself that there was a current prescription in place and doing so over many weeks.”

Despite being in a leadership role, the registrant repeatedly failed to verify prescriptions and instead relied on outdated assumptions. This behavior persisted over several months, with multiple opportunities to rectify it, raising concerns about a continued disregard for patient safety and pharmacy law.

While no actual harm was reported, the risk posed was substantial. The registrant’s justification—namely, pressure due to the COVID-19 pandemic and staffing shortages—did not mitigate the severity of the misconduct. Interviews with her employer revealed that she knowingly instructed dispensers to hand out CDs in her absence, a practice that undermines both legal and ethical standards in pharmacy.

GPhC Determination on Impairment

The panel repeatedly emphasized the registrant’s lack of meaningful engagement with the proceedings. Although she showed limited initial insight—such as acknowledging her failings during interviews with her employer—she failed to demonstrate ongoing remediation. She did not provide any continuing professional development (CPD), reflective pieces, or evidence of efforts to address her shortcomings.

The determination stated:

“The Committee is satisfied that were she allowed to return to unrestricted practice she currently presents a risk of causing serious harm to patients and her fitness to practise is therefore impaired.”

The registrant did not respond to numerous requests for further documentation, did not attend any of the hearings, and only provided minimal communication affirming her suspension compliance.

Sanction

After two years of suspension reviews—with additional 6- and 12-month suspension periods imposed—the committee concluded that further suspension was no longer appropriate. Previous panels had already warned the registrant that continued disengagement would likely lead to removal.

At the August 2025 review, the committee concluded that the registrant had demonstrated no willingness or intent to remediate or return to practice. The panel noted:

“There was every possibility that her failings could have been addressed… However, she had not taken any steps to do this over the previous two years.”

The outcome was the removal of the registrant from the register, effective following the appeal period.

An interim suspension order was also imposed immediately, ensuring that the registrant could not practise during the appeal window.

Key Learning Points for Pharmacy Professionals

Controlled Drugs Require Absolute Vigilance: Pharmacists must ensure that every supply of CDs is based on a valid and current prescription. Dispensing without a prescription, even if driven by workplace pressures, constitutes a serious legal and ethical breach.
Self-Checking is Not Permissible in Routine Practice: SOPs exist to prevent errors and safeguard patient safety. Self-checking controlled substances is only permissible under exceptional circumstances and must be documented accordingly.
Delegation Requires Oversight: Dispensers should not be instructed to supply medications, especially CDs, without supervision by a responsible pharmacist. This undermines both safety and legal compliance.
Prompt Incident Reporting is Essential: Pharmacists are required to report incidents through appropriate channels, including internal systems like DATIX. Delays or omissions can hinder patient safety efforts and regulatory accountability.
Insight and Engagement are Critical in FtP Proceedings: The GPhC expects pharmacists to engage with fitness to practise processes and demonstrate insight, remediation, and willingness to learn. Persistent disengagement signals a lack of professionalism and may ultimately result in removal.
Leadership Comes with Higher Expectations: As a Branch Manager, the registrant was expected to model exemplary practice. Failure to uphold these standards reflects not only on the individual but on the entire profession.

This case highlights the seriousness with which the GPhC views breaches in CD handling and professional responsibility. Pharmacy professionals are urged to maintain rigorous compliance with legal and ethical standards, even under significant workplace pressure.

Original Case Document

The full determination transcript is available to logged in users.