Pharmacist Sanctioned for Inappropriate and Excessive Codeine and Phenergan Supplies
Date of Decision: August 27, 2025
Registrant's Role: Pharmacist
Allegations:
- Failure to implement up-to-date SOPs on high-risk opioid medicines.
- Inappropriate ordering of large quantities of Codeine Linctus and Phenergan Elixir.
- Lack of systems to monitor and audit ordering, sale, and supply of high-risk medicines.
- Specific large orders of Codeine Phosphate and Co-codamol without proper oversight.
Outcome: Conditions imposed for 6 months
GPhC Standards Breached:
- Standard 1 – Provide person-centred care.
- Standard 5 – Use professional judgement.
- Standard 9 – Demonstrate leadership.
Case Summary
Allegations
This case centres on the registrant’s conduct as a Superintendent Pharmacist and Responsible Pharmacist at two community pharmacies: Your Prescriptions Ltd, an online pharmacy, and Al-Shafa Pharmacy. The central concern was the inappropriate procurement and poor governance over the handling of high-risk medicines, particularly Codeine Linctus and Phenergan Elixir, both known for their abuse potential.
The registrant admitted to the following:
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- Full allegations considered by the GPhC
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- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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The original determination transcript is available to registered users.
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- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
- Details of the pharmacy professionals involved