NI GP Pharmacist Suspended for Dishonest Prescribing of Tramadol to Family and Friends

Date of Decision: May 15, 2025

Registrant's Role: Pharmacist

Allegations:

Issued and dispensed prescriptions for controlled drug (Tramadol/Maxitram) without clinical justification
Prescribed medications to individuals with whom she had close personal relationships
Manipulated GP clinical systems, including issuing and cancelling prescriptions
Used login credentials of other staff members to conceal actions
Deleted or altered patient records to hide unauthorised prescribing
Acted dishonestly and without integrity over a 2½ year period

Outcome: 9-month suspension from the register

GPhC Standards Breached:

Standard 1 – Always put the patient first
Standard 2 – Provide a safe and quality service
Standard 3 – Act with professionalism and integrity at all times
Standard 4 – Communicate effectively and work properly with colleagues
Standard 5 – Maintain and develop your knowledge, skills and competence

Case Summary

Allegations

This case involved a General Practice Pharmacist who misused her professional role as an Independent Prescriber over a sustained period to prescribe and facilitate the supply of Tramadol (marketed as Maxitram), a Schedule 3/Class C controlled drug, without clinical justification. The misconduct primarily benefitted individuals with whom the registrant had personal relationships—her partner, family members, and close friends.

The investigation revealed that she had issued over 20 unauthorised prescriptions, engaged in deliberate deletion and cancellation of records, and accessed GP systems using other staff members’ login credentials to conceal her actions. The prescribing patterns often occurred while she was off duty, including occasions where the practice was closed, and lacked appropriate documentation or GP authorisation. Notably, some prescriptions that were supposedly cancelled or deleted were found to have been dispensed and submitted for reimbursement.

This conduct spanned from December 2019 to June 2022 and involved Patients A through E, all known to the registrant. Her actions included printing prescriptions for Tramadol (in 56–120 capsule quantities), Saxenda (a weight-loss medication), and Chloramphenicol, without proper records or clinical need.

Findings

The panel found that the registrant engaged in a calculated and prolonged breach of trust. As an Independent Prescriber, she held a privileged position but used it for personal motives. The misconduct included repeated prescribing of controlled medication to individuals close to her, manipulating patient records to suggest GP authorisation, and attempting to erase traces of her activity from the GP system.

The investigation uncovered multiple serious breaches, including:

Use of other staff login details to obscure accountability
Prescriptions recorded as cancelled but later submitted for payment
Instances where medications were provided without any contemporaneous clinical notes or indication

The registrant admitted all allegations, including the dishonesty involved.

GPhC Determination on Impairment

The panel applied a forward-looking test, focusing not just on the misconduct itself but also on the potential for remediation and recurrence. While the registrant expressed remorse and submitted two reflective pieces, the Committee concluded that she lacked “demonstrable insight” into how her conduct affected patient safety and public trust.

“The allegations do not amount to clinical mistakes. Rather they are evidence of dishonest actions by the Registrant which involved a huge element of concealment.”

Despite over 19 years of unblemished practice, the Committee emphasized that her actions were intentional, dishonest, and executed with a significant degree of planning. There was clear evidence of premeditation, such as using staff profiles, out-of-hours system access, and issuing prescriptions under false pretences.

The Committee acknowledged some mitigating steps—therapy for anxiety and stress, CPD on professional boundaries, and compliance with interim conditions—but held that the risk of recurrence remained too great.

Sanction

The Committee imposed a 9-month suspension from the register, judging it to be the proportionate response given the seriousness of the conduct. While removal from the register was considered due to the gravity of the dishonesty, mitigating factors—including reflections, therapy, and continued positive work during interim conditions—led the panel to conclude that removal was not necessary.

The Committee expects the registrant to:

Complete further training on the impact of dishonesty
Submit a reflective piece showing insight into her misconduct
Provide new references attesting to her honesty and integrity

An interim suspension was also imposed during the 28-day appeal window.

Key Learning Points for Pharmacy Professionals

Misuse of Prescribing Authority is a Serious Offence
Pharmacists must never prescribe or dispense controlled drugs without clear clinical justification and appropriate documentation. Abuse of independent prescribing privileges undermines the foundation of patient trust and regulatory oversight.
Avoid Treating Family and Friends
Treating those with whom you have close personal relationships is strictly prohibited unless in emergencies. The registrant’s failure to observe this boundary was a central element of her misconduct.
Integrity is Non-Negotiable
Deliberately deleting records, using other staff’s credentials, and hiding unauthorised prescribing are clear violations of professional ethics. Integrity encompasses honesty, transparency, and accountability, all of which were absent here.
Insight and Remediation Matter, But Cannot Excuse Dishonesty
While the registrant took steps to reflect and engage in CPD, her limited insight into the wider impact of her actions—on patients, colleagues, and the profession—meant the panel could not find sufficient remediation.
Controlled Drugs Require Enhanced Governance
Tramadol, as a controlled substance, is subject to strict regulatory controls. Pharmacists must act as gatekeepers, not facilitators of misuse. Any lapses in record-keeping or system manipulation related to such substances carry especially serious implications.
Transparency With Investigators is Crucial
The registrant’s failure to provide a full account during the initial investigation led to an unnecessarily complex and prolonged inquiry. Cooperation and transparency are essential when faced with regulatory scrutiny.

This case serves as a powerful reminder of the high ethical and professional standards required of pharmacists, particularly those in positions of trust like Independent Prescribers. The intersection of dishonesty, concealment, and inappropriate prescribing forms a triad of conduct wholly incompatible with the role of a healthcare professional.

Original Case Document

The full determination transcript is available to logged in users.