Superintendent Pharmacist Warned for Failing to Maintain Any CD Registers

Date of Decision: August 26, 2025

Registrant's Role: Pharmacist

Allegations:

Failure to maintain a controlled drugs (CD) register while dispensing Schedule 2 controlled drugs.
Failure to manage and assess risks associated with controlled drug handling as Superintendent Pharmacist.
Breach of statutory responsibilities under the Misuse of Drugs Regulations 2001.

Outcome: Warning issued and published on the GPhC register for 12 months.

GPhC Standards Breached:

Standard 2 – Pharmacy professionals must work in partnership with others.
Standard 5 – Pharmacy professionals must use their professional judgement.
Standard 8 – Pharmacy professionals must speak up when they have concerns or when things go wrong.
Standard 9 – Pharmacy professionals must demonstrate leadership.

Case Summary

Allegations

This case concerns the conduct of the registrant, a Superintendent Pharmacist at a retail pharmacy, between January 2023 and 25 September 2023. During this period, the pharmacy routinely dispensed controlled drugs, including those classified under Schedule 2 of the Misuse of Drugs Act 1971. Despite the high-risk nature of these medications, the pharmacy did not have a controlled drugs (CD) register in place, in breach of the Misuse of Drugs Regulations 2001 (as amended). The responsibility for overseeing this critical aspect of pharmacy governance rested squarely with the registrant.

As the Superintendent, the registrant was expected to assess, manage, and record risks associated with the handling of CDs, and ensure that robust systems were implemented for safe and compliant pharmacy operations. The absence of a CD register represented a significant failing in risk management, regulatory compliance, and leadership.

Findings

The General Pharmaceutical Council’s Investigating Committee established that the registrant did not discharge their responsibilities in relation to the management of controlled drugs. The key findings highlighted the registrant’s lack of understanding and engagement with their statutory duties. The panel found that the registrant failed to demonstrate appropriate oversight or implement the necessary governance structures to safeguard controlled drugs in the pharmacy.

The lack of a CD register not only exposed the pharmacy to potential misuse or diversion of high-risk medicines, but also increased the risk of patient harm. The panel noted that this omission reflected a concerning gap in the registrant’s understanding of the superintendent’s statutory role.

GPhC Determination on Impairment

The Committee assessed that while the failings did not currently amount to a fitness to practise impairment requiring conditions or suspension, they were nonetheless serious. The conduct demonstrated a clear breach of statutory duties and GPhC professional standards.

The Committee chose to issue a warning as a formal response to the misconduct. This decision was informed by the fact that the registrant’s actions presented a potential risk to patient safety and public confidence, but did not cross the threshold for a more severe sanction.

Sanction

The GPhC issued a formal warning to the registrant. This warning will remain published on the public register for 12 months. In its warning, the Committee emphasised the potential dangers of failing to manage controlled drugs properly:

“Failing to properly discharge the duties of the Superintendent Pharmacist, including in respect of the proper management of controlled drugs, can increase the risk of misuse or diversion which could lead to patient harm. It also has the potential to undermine public trust and confidence in the profession.”

The Committee also reiterated that all pharmacies must have robust and adequate systems in place for managing CDs, and that the Superintendent Pharmacist bears ultimate responsibility for these systems.

Key Learning Points for Pharmacy Professionals

Strict Compliance with CD Legislation: This case reinforces the importance of maintaining a CD register as required by law. Schedule 2 controlled drugs, such as morphine, oxycodone, or methadone, require careful monitoring to ensure accountability and patient safety.
Leadership Responsibility: Superintendent Pharmacists must exercise effective leadership and ensure all statutory requirements are met within the pharmacy. Passive oversight or lack of engagement is unacceptable.
Risk Management is Critical: Identifying and mitigating risks around high-risk medications is a core part of professional responsibility. Failure to do so not only risks patient harm but also regulatory action.
Maintaining Public Confidence: Even administrative failings can damage public trust in pharmacy professionals. Pharmacists must uphold the highest standards in governance and documentation.
Speak Up and Take Initiative: The GPhC standard to “speak up when things go wrong” was breached in this case, as the registrant did not take proactive steps to correct the absence of a CD register.

This case serves as a reminder that professional accountability extends beyond direct patient interactions to encompass every aspect of safe pharmacy operation—including compliance, documentation, and leadership.

Original Case Document

The full determination transcript is available to logged in users.