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:

Insecure storage of dispensed medicines.
Patient information left visible in the pharmacy environment.
Inadequate refrigeration security for cold chain medicines.
A controlled drug discrepancy in record-keeping.
Failure to maintain the Responsible Pharmacist log accurately.
Staff using their own NHS Smartcards improperly.

These issues pointed to systemic management lapses under the registrant’s supervision.

Findings

The GPhC’s Investigating Committee concluded that the registrant failed to manage and oversee key aspects of pharmacy operations, particularly in relation to high-risk medication supplies and patient safety measures. While there was no direct evidence of inappropriate supply to patients, the lack of governance and documentation surrounding the excessive orders raised significant red flags.

It was further noted that the registrant accepted responsibility for the failures and had since taken corrective actions to address the shortcomings. The pharmacy was found to be compliant with GPhC standards at the time of the most recent inspection, suggesting that remedial efforts had been effective.

GPhC Determination on Impairment

While this case did not involve a formal fitness to practise impairment determination or hearing, the Committee considered the seriousness of the regulatory breaches. The registrant’s actions were assessed in the context of the GPhC’s professional standards. Their failure to ensure safe practice and system oversight amounted to a breach of several key standards.

The Committee emphasized that even in the absence of proven harm to patients, the potential for risk and erosion of public trust in the pharmacy profession required formal acknowledgment. It was acknowledged that the registrant cooperated fully with the investigation and showed insight and willingness to improve.

Sanction

The Committee issued a formal warning, which will remain on the public register for 12 months. This outcome was chosen to reflect the seriousness of the breach and to act as a deterrent to other pharmacy professionals. The Committee stated:

“A warning is required to send a clear message to pharmacy professionals and the public that any breach of this nature undermines public confidence in the profession, puts patients at risk and is a breach of the Standards for Pharmacy Professionals.”

They also noted that similar conduct in future would likely result in more severe regulatory action.

Key Learning Points for Pharmacy Professionals

Controlled Substance Oversight Is Crucial: Excessive or unexplained ordering of controlled medicines like Codeine Linctus, even in the absence of diversion or misuse, is a serious red flag. Pharmacists must have robust stock control, risk assessments, and accountability procedures in place.
Professional Standards Apply Beyond Clinical Errors: Regulatory scrutiny is not limited to dispensing errors or direct patient harm. Systemic failures in governance, leadership, and operational controls can equally trigger regulatory action.
Visibility of Patient Information Is a Breach: Leaving patient details visible within the pharmacy breaches confidentiality obligations. All staff must be vigilant about maintaining privacy and securing sensitive information.
Smartcard Usage Policies Must Be Enforced: Allowing others to use NHS Smartcards is a serious breach of information governance and can compromise audit trails. Pharmacists must ensure secure and compliant use of digital systems.
Responding to Investigations with Transparency Helps: The registrant’s willingness to accept the shortcomings and improve pharmacy systems contributed to the relatively lenient outcome. Regulatory bodies value transparency, insight, and prompt corrective actions.
Leadership Responsibilities Are Non-Negotiable: Pharmacists in charge must ensure that systems for patient safety, legal compliance, and operational integrity are not only in place but are actively monitored and enforced.

This case serves as a sobering reminder that pharmacy professionals are expected to uphold the highest standards of care, governance, and leadership at all times. Even indirect or systemic failings, if left unchecked, can attract regulatory consequences and impact professional standing.

Original Case Document

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