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:

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