NI Superintendent Pharmacist Warned for Widespread Governance Failures at Belfast Pharmacy

Date of Decision: August 28, 2025

Registrant's Role: Pharmacist

Allegations:

Failure to maintain the Pharmacy Record at Earlswood Pharmacy under the Medicines Act 1968 and Responsible Pharmacist Regulations.
Absence of appropriate and accessible Standard Operating Procedures (SOPs).
Lack of verifiable audit trails for delivery of medicinal products.
Inadequate maintenance of Controlled Drug (CD) registers.
Failure to conduct periodic stock audits of controlled drugs.
Absence of a reliable near miss/error recording system.
Inadequate record-keeping of extemporaneously prepared unlicensed medicines.

Outcome: Warning

GPhC Standards Breached:

Standard 6 – Maintain clear and accurate records
Standard 3 – Deliver safe and effective care
Standard 1 – Provide person-centred care
Standard 7 – Respect and maintain the person’s confidentiality and privacy (implied in record-handling deficiencies)

Case Summary

Allegations

This case concerns a series of serious governance and compliance failings by the registrant, who served as the superintendent pharmacist and majority shareholder of Chemcare (NI) Ltd, operating two pharmacies in Belfast. The allegations related specifically to Earlswood Pharmacy, which ceased operations in October 2021.

The Society alleged that, between 2018 and 2021, the registrant failed to ensure legal and professional standards across multiple key operational domains. Specific concerns included:

Incomplete or entirely missing entries in the Responsible Pharmacist (RP) logbook, including over 100 instances where the registrant did not sign in as being in charge of the premises.
Lack of adequate SOPs addressing essential functions such as medicine delivery and change of RP, as well as failure to review or make SOPs readily accessible.
No verifiable audit trail for the delivery of medicines, contravening Section 6 of the Professional Standards and Guidance.
Improper or missing controlled drug records, including failure to log returned Schedule 2 drugs and incorrect/incomplete supplier details.
Discrepancies in CD stock audits, as seen with Longtec 5mg tablets.
Only two logged entries in the near miss/error log over a span of several years.
Incomplete and undated records of extemporaneously prepared and dispensed unlicensed medicines.

Findings

The registrant admitted all factual allegations and the associated misconduct. The Committee confirmed these admissions and found all allegations proved.

The deficiencies presented significant potential for patient harm and were indicative of systemic governance failures. Although no actual harm was reported, the panel emphasised that the lack of basic pharmacy controls placed patient safety at risk.

“The bottom line is that it fell to the Registrant as the Superintendent Pharmacist to ensure that the Earlswood Pharmacy operated in accordance with legal requirements… to ensure that this pharmacy operated safely and effectively for the public.”

GPhC Determination on Impairment

Despite acknowledging the registrant’s insight, remorse, and remediation, the Committee found that the wider public interest demanded a finding of current impairment. This decision was anchored in the need to uphold professional standards and public confidence.

The Committee specifically cited case law emphasizing that a finding of impairment may still be necessary even when the practitioner no longer poses a personal risk, to maintain public trust in the profession.

The registrant’s insight was evident through his cooperation during investigations and the decisive closure of the Earlswood Pharmacy. This closure, although drastic, was seen as a responsible act to prevent recurrence of such issues.

Sanction

After considering all available sanctions, the Committee issued a formal Warning. The rationale included:

The absence of actual patient harm.
The registrant’s early admission, genuine remorse, and long unblemished career.
The proactive decision to close the problematic pharmacy and the registrant’s continued issue-free practice at another site for four years.

More severe sanctions, such as Conditions or Suspension, were deemed disproportionate. The Warning will be publicly visible on the Society’s website and register for up to two years, serving both as a deterrent and as a reaffirmation of professional accountability.

Key Learning Points for Pharmacy Professionals

Governance is a Core Responsibility of Superintendent Pharmacists: Delegation does not absolve accountability. Even when not personally working on-site, systems must be in place to ensure safe practice.
Maintain Complete and Accurate Pharmacy Records: Deficiencies in RP logs, SOPs, and CD registers are not administrative oversights—they are breaches of legal duties with patient safety implications.
Controlled Drug Management Must Be Rigorous: Inaccuracies in CD registers or stock reconciliation, especially with Schedule 2 substances like Longtec (oxycodone), pose a serious risk and are legally indefensible.
Near Miss Recording Is Essential for Safe Practice: The absence of a culture of reporting and reviewing near misses inhibits learning and opens the door for repeat errors.
Extemporaneous Preparations Require Robust Documentation: These high-risk medicines must be traceable with clear, contemporaneous records to ensure accountability and compliance.
Remediation and Insight Matter: Early admissions, proactive closures, and a history of responsible practice can significantly influence the sanction outcome, as seen in this case.
Public Confidence Trumps Individual Impact: Even when risks are mitigated, the need to uphold public trust can necessitate findings of impairment and formal sanctions.

This case reinforces the high expectations placed upon those in leadership roles within pharmacy practice and the serious consequences that follow systemic failings—even when patient harm does not occur.

Original Case Document

The full determination transcript is available to logged in users.