Pharmacist Warned for Falsifying Controlled Drugs Register Entry Involving Oxycodone

Date of Decision: October 27, 2025

Registrant's Role: Pharmacist

Allegations:

• Deliberately made a false entry in the Controlled Drugs register to conceal a discrepancy involving Oxycodone 10mg tablets.

Outcome: Warning issued; remains on the public register for 12 months

GPhC Standards Breached:

• Standard 2 – Work in partnership with others
• Standard 5 – Use professional judgement
• Standard 6 – Behave professionally
• Standard 8 – Speak up when things go wrong
• Standard 9 – Demonstrate leadership

Case Summary

Allegations
The case centred around the registrant’s conduct while serving as the Responsible Pharmacist at a community pharmacy. A referral was made to the General Pharmaceutical Council (GPhC) following an internal investigation by the registrant’s employer. The investigation uncovered that the registrant had made a deliberate false entry in the Controlled Drugs (CD) register concerning Oxycodone 10mg tablets. Specifically, there was a discrepancy of 56 tablets. To conceal the shortfall, the registrant amended the register to reflect that a patient had been dispensed 112 tablets, when in fact only 56 had been supplied. This act of falsification was intended to cover up the missing stock rather than address the root cause of the discrepancy.

Findings
During a local level inquiry, and subsequently in his formal response to the GPhC, the registrant admitted to the dishonest act. He acknowledged that he had altered the CD register entry to hide the error rather than escalate or resolve the issue properly. This admission of dishonesty was a key element of the panel’s findings, reinforcing the seriousness of the misconduct.

The panel determined that the registrant’s actions constituted a clear breach of multiple professional standards. The falsification of a CD register—a legally required document used to monitor and audit the use of high-risk, controlled medications—poses significant risks. It compromises the safety and accountability systems designed to prevent misuse or diversion of controlled substances.

GPhC Determination on Impairment
Although the matter was serious, the Committee chose not to proceed with a full Fitness to Practise impairment hearing. The registrant’s conduct, while a serious breach of trust and professional standards, was assessed to be isolated. The panel took into account the registrant’s candid admission of guilt, both locally and to the regulator, and the insight he demonstrated into the incident. The GPhC considered this level of reflection and acceptance to be mitigating factors.

“[The Registrant]’s actions have the ability to undermine public confidence in the pharmacy profession. Honesty and integrity are key cornerstones to the pharmacy profession, and [The Registrant]’s actions were a clear departure from the standards required.”

The panel recognised that dishonesty in any form is grave. However, in this instance, they acknowledged that the conduct was a one-off event and that the registrant had shown an appropriate level of insight and remorse.

Sanction
As a result of their findings, the GPhC Investigating Committee issued a formal warning. This warning is set to remain visible on the public register for 12 months. The warning serves both as a public record of the regulatory response and as a deterrent against future misconduct.

The wording of the warning explicitly reminds the registrant of their obligations to uphold honesty and integrity, use sound professional judgement, and report issues transparently. It also reinforces the importance of leadership and collaborative practice, especially when discrepancies or patient safety risks arise.

Key Learning Points for Pharmacy Professionals

1. Integrity in Controlled Drug Handling: Pharmacists must maintain rigorous accuracy when managing controlled drug registers. These documents are legally binding and essential for tracking high-risk medications such as Oxycodone.
2. Importance of Speaking Up: Attempting to hide a discrepancy, even with perceived good intentions, is never acceptable. Pharmacists must report and investigate anomalies, not conceal them.
3. Dishonesty Is Always Serious: Even a single instance of dishonesty can lead to significant professional consequences. This case highlights that while mitigation may lessen the outcome, breaches of trust remain a serious issue.
4. Value of Insight and Remorse: Demonstrating genuine reflection and understanding of one’s failings can impact the regulatory outcome. The GPhC acknowledges insight as a key factor in rehabilitation and public protection.
5. Leadership and Responsibility: Being the Responsible Pharmacist entails more than overseeing a dispensary—it involves setting a standard for ethical behaviour and accountability.

This case is a clear reminder that honesty and transparency are non-negotiable values in pharmacy practice. Even under pressure, pharmacists must act with integrity, uphold professional standards, and never compromise the trust placed in them by the public, their colleagues, or the profession.

Original Case Document

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