Pharmacist Issued Warning Over Improper Mezolar Claims for Discontinued Medication

Date of Decision: September 8, 2023

Registrant's Role: Pharmacist

Allegations:

• Submitted or permitted claims for Mezolar dispensing that did not occur.
• Lacked effective systems to identify and properly code non-dispensed prescription items.
• Knew Mezolar was not dispensed but still submitted claims, representing a systemic failure.
• Failed to stop repeat prescriptions for discontinued controlled drug and lacked documentation of communication with GP.
• Did not supervise controlled drug prescribing properly and failed to keep records after medication interventions.

Outcome: Warning issued

GPhC Standards Breached:

• Standard 2.1.2 – Effectively control and manage the sale or supply of medicinal and related products paying particular attention to those with a potential for abuse or dependency.
• Standard 2.1.6 – Ensure that you do not, whether by your actions or omissions, create a risk to patient care or public safety.
• Standard 2.1.11 – Avoid treating yourself or anyone with whom you have a close personal relationship except for minor ailments or in an emergency.
• Standard 2.1.12 – Ensure you are aware of and adhere to all relevant legislation, and all current standards and guidance which apply to your practice.
• Standard 2.3.1 – Complete records promptly or as soon as reasonably practicable after the patient intervention or activity has occurred.
• Standard 2.3.3 – Ensure all entries in any record are accurate, clearly and legibly written and attributable.
• Standard 3.1.7 – Take all steps that are reasonably necessary to ensure that recorded information is correct and complete. Do not omit relevant information.

Case Summary

Allegations

The case revolved around the registrant, a superintendent pharmacist, who submitted false claims for Mezolar—a Schedule 2 controlled drug—between April 2017 and December 2018. The medication had been discontinued for the patient, his mother, in April 2017 following a switch to Butec patches. Despite this, prescriptions containing Mezolar continued to be received and submitted for payment as if they were dispensed, even though no such supply had been made. These errors extended over a period of approximately one year and involved about 15 occasions of incorrect submissions, totaling £411.54.

The Pharmacy Inspector’s investigation revealed a significant discrepancy: only two of the 17 prescriptions had matching entries in the controlled drug register. The remainder—despite being coded for supply—had no corresponding records or wholesaler purchase history, indicating they were never actually dispensed.

Findings

The registrant admitted to all five revised allegations brought against him. He acknowledged that Mezolar prescriptions were submitted for payment without being dispensed, and without effective coding to indicate non-supply. The investigation confirmed that no actual supply of Mezolar occurred after its discontinuation in April 2017, yet payments were claimed and received. The registrant’s failings were systemic: there was no procedure to flag and segregate invalid prescriptions, no communication with the GP to prevent continued erroneous prescriptions, and no records of attempted interventions.

Although the registrant claimed that the issue resulted from a lack of clarity in the GP’s practice, the Committee found that he failed to act on numerous opportunities to correct the situation, choosing instead to process payments for items not dispensed.

The Committee determined that this constituted a “fundamental and systemic failure of management and control” and a “substantive breach of integrity.”

GPhC Determination on Impairment

The panel found the registrant’s fitness to practise to be currently impaired. Citing relevant case law, it considered both the potential risk to the public and the wider impact on professional standards and public confidence. The panel accepted that there was no dishonesty, actual harm, or intention to mislead patients, but the cumulative failures indicated a serious breach of professional duty.

Although the registrant demonstrated insight and had undertaken remedial actions—including updated SOPs and written apologies—the Committee noted he tended to minimize his own responsibility, attributing blame to GP prescribing habits rather than his own regulatory obligations.

The Committee stated:

“Whilst not dishonest, his conduct does represent a substantive breach of integrity.”

Further, the registrant’s conduct met several criteria for impairment, including potential risk to the public, bringing the profession into disrepute, and undermining public trust in pharmacists’ integrity.

Sanction

Despite the seriousness of the misconduct, the Committee imposed a Warning. It considered this the most proportionate response given:

• The registrant’s previously unblemished record since 1985.
• His cooperation with all investigative bodies.
• Full reimbursement of the wrongly claimed amount.
• Documented insight, remorse, and steps to remedy procedural gaps.
• His intent to retire from pharmacy practice and remove himself from the register.

Conditions or suspension were deemed unnecessary or unworkable, given the registrant’s retirement. Removal from the register was not pursued.

The issued warning serves to underline the seriousness of the misconduct while balancing the registrant’s cooperation, remediation, and retirement plans.

Key Learning Points for Pharmacy Professionals

1. Controlled Drug Oversight Must Be Rigorous
   Handling of Schedule 2 controlled drugs demands meticulous documentation and reconciliation. Failing to do so—even without dishonest intent—can breach integrity and regulatory standards.
2. Personal Involvement Does Not Excuse Lapses
   Pharmacists must avoid dispensing or processing prescriptions for close relatives beyond minor ailments. The registrant’s familiarity with his mother’s medication led to procedural complacency.
3. Systemic Management Failures Are Not Administrative Errors
   Submitting prescriptions for payment when no supply occurred cannot be excused as an oversight. These are systemic failures, not clerical mistakes.
4. Document Every Intervention
   Any communication with prescribers regarding erroneous prescriptions must be documented. In this case, the lack of records undermined the registrant’s claims of addressing the issue.
5. Public Confidence Relies on Transparency and Accountability
   Even in the absence of patient harm, the appearance of improper claims can seriously damage trust in pharmacy professionals. Upholding standards protects the profession’s reputation.
6. Mitigation Depends on Prompt Remediation and Insight
   The registrant avoided harsher sanctions by showing insight, taking remedial action, and voluntarily leaving the profession. However, his delay in accepting full responsibility was noted.

This case underscores the importance of robust systems for dispensing, coding, and claiming payments, especially where controlled drugs are involved. It highlights the pharmacist’s duty to maintain integrity, document interventions, and proactively manage prescription errors—even when patients are family members.

Original Case Document

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