Warning Issued for Pharmacist Over Excessive Codeine and Phenergan Orders Without Oversight
Date of Decision: September 11, 2025
Registrant's Role: Pharmacist
Allegations:
- Excessive and unaccounted ordering of Codeine Linctus and Phenergan Elixir.
- Failure to maintain oversight of pharmacy systems related to stock ordering and medication safety.
- Breaches in secure storage of dispensed medication and patient information.
- Improper maintenance of controlled drug records.
- Inaccurate responsible pharmacist log.
- Inappropriate use of NHS Smartcards by staff.
Outcome: Warning issued and published on the register for 12 months.
GPhC Standards Breached:
- Standard 1 – Pharmacy professionals must provide person-centred care.
- Standard 7 – Pharmacy professionals must respect and maintain a person’s confidentiality and privacy.
- Standard 9 – Pharmacy professionals must demonstrate leadership.
Case Summary
Allegations
This case revolves around the registrant, a pharmacist serving as the Responsible Pharmacist at a retail pharmacy in Benfleet. Concerns were raised following an intelligence referral which triggered a GPhC inspection. At the heart of the allegation was the pharmacy’s excessive and unexplained ordering of controlled and potentially abused medications: Codeine Linctus (200ml) and Phenergan Elixir. Specifically, between February and September 2023, the pharmacy ordered approximately 2942 bottles of Codeine Linctus and 410 bottles of Phenergan, significantly exceeding typical usage patterns.
The investigation determined that these orders were made without proper oversight, risk assessments, or accountability. In addition, the GPhC inspection in November 2023 revealed a series of operational failures:
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- Full allegations considered by the GPhC
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- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
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