Newly Qualified Pharmacist Issued Warning After Unsafe Dispensing, Damaged CD Packaging, and Data Mishandling Across Multiple Pharmacies

Date of Decision: September 17, 2025

Registrant's Role: Pharmacist

Allegations:

Dispensing MST Continus 10mg tablets in damaged packaging to a patient.
Repeated failures to check and prepare prescriptions correctly.
Taking photographs of prescriptions and medication labels on a personal phone.
Possession and attempted removal of confidential patient information from pharmacies.
Failing to ensure correct contents in prescription bags.
Placing Diazepam boxes containing tablets in confidential waste.
General disorganisation and untidiness leading to prescription errors.

Outcome: Warning

GPhC Standards Breached:

Standard 7 – Respect and maintain a person’s confidentiality and privacy: Breached through taking images of prescription information and attempting to remove patient-identifiable documents without justification.

Case Summary

Allegations

This case centres around a newly qualified pharmacist who faced allegations spanning a 15-month period at three separate pharmacy locations where he worked as a locum. The General Pharmaceutical Council (GPhC) brought forward multiple allegations of misconduct and deficient professional performance, primarily relating to unsafe dispensing practices, poor prescription handling, and breaches of patient confidentiality.

The most striking early allegation stemmed from a serious error on 3 August 2022, when the pharmacist dispensed MST Continus 10mg tablets in visibly damaged packaging to a patient. The patient, known as Patient A, was understandably distressed upon discovering that the medication blister pack was pierced and marked with pen scribbles. This initiated a formal complaint, and the pharmacist admitted to unintentionally damaging the packaging during checking.

Further concerns arose during his repeated engagements at Tesco Pharmacy in Haverfordwest and Halifax. These included errors in prescription checking that led to missing items in medication bags, improper documentation of controlled drugs (though not proven to be incompetent), and one serious incident involving the possession of confidential patient documentation with the intention of removing it from the premises.

One of the more alarming concerns was the registrant’s handling of sensitive data. He admitted to photographing prescriptions and medication labels using his personal mobile phone, claiming it was for learning purposes. Although he asserted no identifiable information was captured, the practice itself constituted a clear breach of professional standards.

Another confirmed breach occurred when he discarded unopened Diazepam boxes in confidential waste. While not malicious, these actions demonstrated a lack of awareness regarding the safeguarding of controlled substances and potential risks to public safety.

Findings

The panel found several facts proven by either admission or evidence. The errors were not isolated but rather repeated across three different pharmacies. Crucially, the GPhC determined that:

The registrant had an unsafe and overly cautious checking process which involved using a pen to physically press on blister packs, resulting in damage to packaging.
Prescription bags were sent out incomplete on multiple occasions, posing a direct risk to patient safety.
He demonstrated a consistent inability to maintain a tidy and methodical work environment, which increased the potential for mix-ups and missing items.
He admitted to taking prescription-related photos on his phone and possessing confidential materials without clinical justification.

Despite numerous reminders and interventions from colleagues, the registrant did not initially respond appropriately to feedback or alter his practice during the material period.

The committee found misconduct (primarily in data handling) and deficient professional performance (inaccuracy in prescription dispensing and chaotic working methods) had both occurred.

“The failings that have been found by the Committee amount to a breach of Standard 7 due to the inappropriate management of confidential patient material… the failure to conduct effective prescription checks and the mishandling of patient medication amounted to deficient professional performance that jeopardised patient safety.” — Fitness to Practise Committee Determination

GPhC Determination on Impairment

In assessing fitness to practise, the GPhC considered whether the registrant posed a risk to the public, had breached fundamental professional principles, or brought the profession into disrepute.

Despite the seriousness of the breaches, the panel noted significant improvements. The registrant, now employed in a stable, supervised environment, demonstrated genuine insight, reflected deeply on past failings, and completed targeted training, including a course in data protection (GDPR).

They acknowledged that his previous errors were remediable and, crucially, had already been remedied. Nonetheless, due to the seriousness of the misconduct — particularly surrounding confidential patient information — the committee found his fitness to practise was impaired on public interest grounds alone.

Sanction

Given the registrant’s remediation, the GPhC determined that a warning was the proportionate response. Conditions or suspension were deemed unnecessary due to the absence of ongoing risk to patient safety. The warning will remain published on the register for 12 months.

The committee emphasised that the warning serves to publicly mark the unacceptable standards previously demonstrated and to maintain trust in the profession.

Key Learning Points for Pharmacy Professionals

Safe Dispensing Practices Must Be Maintained at All Times: Even newly qualified pharmacists are expected to uphold rigorous standards. The use of inappropriate checking tools (e.g., pens on blister packs) can physically damage medication, leading to serious patient complaints and professional consequences.
Handling of Controlled Drugs Requires Heightened Vigilance: Misplacing or mishandling controlled drugs like Diazepam, even if unintentional, poses risks to public safety and can lead to regulatory scrutiny.
Confidential Patient Information Must Be Treated with the Utmost Care: Photographing prescriptions or removing documents from the pharmacy breaches Standard 7 and undermines patient trust. Even in the name of learning, such actions are unacceptable.
Locum Work Requires Self-Awareness and Structure: The registrant’s choice to locum early in his career, without the benefit of a stable environment or mentorship, contributed to his poor practice. Pharmacists must assess whether their work arrangements support safe, reflective practice.
Insight and Remediation Are Vital: The registrant’s commitment to professional development, targeted training, and responsiveness to supervision were key factors in mitigating the sanction. His recognition that “over-checking” introduced risk was a notable turning point.
Confidence and Communication Are Core Skills: This case also highlights that over-cautiousness and lack of confidence can lead to clinical errors. Developing clear communication strategies, both with patients and colleagues, is essential to safe practice.

This determination serves as a sobering reminder that professional standards apply equally to all pharmacists, regardless of experience level. A supportive working environment and the courage to seek guidance can be critical in navigating the challenges of early practice.

Original Case Document

The full determination transcript is available to logged in users.