Repeated Dispensing Failures and CDs Mismanagement Lead to Suspension of Superintendent Pharmacist and RP

Date of Decision: September 12, 2025

Registrant's Role: Pharmacist

Allegations:

Multiple inappropriate supplies of Schedule 2 Controlled Drugs without valid prescriptions
Falsification of the Patient Medication Record (PMR) to record false “owed” medication entries
Incorrect records indicating emergency supplies where none were authorised or lawful
Dishonest claims regarding Responsible Pharmacist status on days absent from the pharmacy
Inappropriate delegation of duties to unregistered staff
Failure to supervise or correct unsafe practices of another pharmacist
Repeated unsafe supplies of medicines, including methadone and diazepam
Misleading inspectors and investigators during pharmacy visits
Acting dishonestly and without integrity

Outcome: Suspension for 12 months (for both registrants)

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 2 – Work in partnership with people
Standard 3 – Communicate effectively
Standard 4 – Maintain, develop and use professional knowledge and skills
Standard 5 – Use professional judgement
Standard 6 – Behave in a professional manner
Standard 7 – Respect and maintain a person’s confidentiality and privacy
Standard 8 – Speak up when they have concerns or when things go wrong
Standard 9 – Demonstrate leadership

Case Summary

Allegations

This GPhC determination involved two pharmacists—referred to as “the registrants”—both of whom worked at a pharmacy where systemic and dangerous practices were identified. One pharmacist was the Superintendent Pharmacist and Responsible Pharmacist (RP) on most relevant days, while the other was a locum pharmacist. Both were held to account for serious professional misconduct.

The allegations were extensive and involved:

Controlled Drug Mismanagement: Methadone and other Schedule 2 CDs were frequently supplied without valid prescriptions. One registrant, while acting as RP, allowed methadone to be dispensed under an old prescription despite the existence of a new one. In another incident, diazepam was supplied in large quantities without any prescription.
Record Falsification: On numerous occasions, the PMR was altered to falsely record emergency supplies or owed items. These entries were dishonest and misleading. At times, medication was marked as “owed” when the full supply had already been given, thus avoiding detection of unlawful supply.
Dishonesty and RP Deception: One of the registrants claimed to be the RP on days they were not present at the pharmacy, submitting incorrect Responsible Pharmacist records. This created a misleading paper trail that hindered regulatory oversight.
Inadequate Supervision and Delegation: The Superintendent Pharmacist failed to adequately supervise staff, including unregistered individuals who were allowed to prepare and supply CDs. Tasks were inappropriately delegated to non-qualified team members, exposing patients to significant risks.
Failure to Intervene in Unsafe Practices: One registrant did not stop or report the other’s unsafe practices, despite clear knowledge of the issues. For example, incorrect daily methadone dosages were supplied repeatedly without taking appropriate corrective action.
Misleading Investigators: Both registrants gave inconsistent and at times misleading explanations to GPhC inspectors, further undermining their credibility.

The panel considered the misconduct “sustained, repeated and systemic,” affecting a significant number of patients and involving high-risk medications.

Findings

Both registrants were found to have breached almost every key standard of the GPhC’s professional framework. Notably, dishonesty was central to the findings—especially around false records, misuse of emergency supply rules, and claims of being the RP when not present.

One quote from the determination starkly captured the panel’s concerns:

“The public, and those who work with pharmacy professionals, are entitled to expect that a pharmacist will act honestly and with integrity. In this case, both registrants fell short of that expectation in serious ways.”

While both accepted some wrongdoing, the panel noted inconsistencies in their evidence, minimisation of responsibility, and lack of full acknowledgment of the systemic risks created.

The Superintendent Pharmacist, in particular, was criticised for setting a poor example and enabling unsafe practices over a sustained period.

GPhC Determination on Impairment

The Fitness to Practise Committee assessed that both registrants’ fitness to practise was impaired on public protection grounds and in the wider public interest. This was not just a matter of individual errors but a pattern of misconduct affecting multiple domains of safe pharmacy practice.

Although both expressed partial insight and submitted references or testimonials, the panel considered their remediation efforts insufficient. Neither had completed relevant training (e.g. on controlled drugs or supervision responsibilities), and their reflections lacked depth.

Importantly, the panel found a risk of repetition unless meaningful remediation occurred. It was also vital to uphold public confidence in the pharmacy profession, especially given the centrality of CDs and safeguarding vulnerable patients.

Sanction

After reviewing the full range of sanctions, the committee imposed a 12-month suspension on each registrant. While erasure was considered due to the gravity of dishonesty and CD mismanagement, the panel ultimately found that:

There was a realistic prospect of remediation,
The registrants were not fundamentally incapable of safe practice,
Suspension would adequately protect the public while allowing for possible return to practice.

The panel concluded:

“A 12-month suspension is necessary and proportionate in light of the seriousness of the misconduct and its impact on public confidence.”

Both registrants will be subject to review hearings before returning to the register, where evidence of learning, reflection, and remediation will be expected.

Key Points About WhatsApp Usage in the Case:

Coordination and Delegation via WhatsApp: The registrants used WhatsApp to communicate about daily pharmacy operations. In particular, they exchanged messages about which prescriptions had arrived and what items could be handed out.
Evidence of Responsibility: The Superintendent Pharmacist argued that they had given specific instructions via WhatsApp to the locum pharmacist (Registrant 2) about when and what medication could be supplied. This included directives to ensure that only medications with valid prescriptions were to be dispensed.
Panel’s View on WhatsApp Instructions: While these messages were presented to demonstrate delegation and control, the panel found that the Superintendent Pharmacist failed to provide adequate oversight and that mere messaging was not a substitute for proper supervision—especially concerning the supply of Controlled Drugs.
Limitations of WhatsApp Communication: The messages were not considered sufficient to discharge the Superintendent’s professional responsibility. Even if the messages indicated some awareness of the risks or reminders of correct procedures, the actual outcomes—multiple unlawful supplies and falsified records—showed that the systems in place were inadequate.

“Although the registrant referred to WhatsApp messages as evidence of supervision and instruction, the panel determined that this mode of communication did not constitute effective oversight or delegation, particularly in the context of repeated serious errors.”

In essence, the use of WhatsApp was not inappropriate in itself, but the panel criticised overreliance on remote messaging in place of active, in-person supervision, especially given the serious nature of the tasks being discussed.

Key Learning Points for Pharmacy Professionals

Controlled Drug Regulations Must Be Followed Precisely
Deviating from CD protocols—especially by supplying without valid prescriptions—poses direct risks to patient safety and public trust.
Dishonesty Erodes Professional Trust
The falsification of records and misleading of inspectors demonstrate why integrity is a non-negotiable aspect of professional life.
Responsibility Cannot Be Delegated Away
A Superintendent Pharmacist has a duty to lead by example and ensure systems are safe. Delegating to unregistered staff without oversight is reckless.
Record-Keeping is a Regulatory Obligation, Not an Option
The PMR and RP log are legal documents. False entries or backdating are serious misconduct.
You Are Accountable for Colleagues’ Unsafe Practices if You Fail to Intervene
Observing and permitting unsafe practices without challenge is itself a breach of duty.
Public Confidence Depends on Visible Accountability
In imposing a 12-month suspension, the panel emphasised that the pharmacy profession must be seen to uphold high standards, particularly where vulnerable patients and high-risk medicines are involved.

Original Case Document

The full determination transcript is available to logged in users.