GPhC Case Review: Pharmacy Technician’s Controlled Drug Register Dishonesty Leads to Extended Conditions of Practice

Date of Decision: August 24, 2026

Registrant's Role: Pharmacy technician

Allegations:

• Making a false entry in the Morphine Sulphate (MST) 10 mg register on 20 September 2021 by adding 132 tablets in order to make the recorded stock balance.
• Making false entries relating to Longtec 5 mg and 10 mg on 10 November 2021, including recording that 21 tablets of each strength had been supplied to a patient when the last actual supply had occurred in March 2021, and then recording that those tablets had been returned by the patient's carer even though they had not been supplied on that date.
• Making another false MST 10 mg register entry on 24 November 2021 by adding 120 tablets to balance the stock.
• Making false entries in the Tranquilyn and Medikinet register, including adding 30 tablets to a patient's records and later making further amendments involving the addition of 26 tablets and removal of 42 tablets, with explanations that entries had been written in the wrong register or under the wrong brand.
• Recording a false missed-delivery entry in the MST register on 18 December 2021, stating that 258 MST 10 mg tablets had been received when no such delivery had taken place.
• Retrospectively changing Shortec 5 mg register entries, recording supplies of 21 tablets rather than 42 tablets for two previous dispensing dates.
• Making inaccurate MST 60 mg entries relating to a patient, including entering the wrong supply date, completing balance checks as correct when they were not, adding a second supply of 14 tablets to make the register balance, and later removing that entry.
• Making false entries in the MST 10 mg CD register in January 2022, including recording that a medicine had been supplied with one tablet missing and then adding that tablet back into stock, followed by an incorrect balance check.
• Falsely recording receipt of 48 MST 10 mg tablets on 4 February 2022 when they had not been received, followed by an inaccurate balance check.
• Falsely recording receipt of 56 MST 15 mg tablets on the same date, again followed by an incorrect balance check.
• Making a false Shortec 5 mg entry stating that a patient's supply had been written out twice.
• Making a false entry for a supply of 56 methylphenidate 10 mg tablets and subsequently recording multiple controlled drug balance checks as correct when they were not.
• Falsely recording that a patient had received 21 Shortec 5 mg tablets rather than 42 and completing a series of balance checks as correct despite discrepancies.
• Falsely recording a supply of 21 Xaggitin XL 36 mg tablets to a patient who had not received the medicine since February 2022 because they had moved away, together with issues concerning the medicine being placed in out-of-date stock.
• Failing to ensure that amendments to controlled drug registers were witnessed by another member of staff as required.
• Acting misleadingly and/or dishonestly by knowingly making entries that were inaccurate.

Outcome: The existing Conditions of Practice Order was varied and extended for a further 12 months

GPhC Standards Breached:

• Standard 2 – Pharmacy professionals must work in partnership with others.
• Standard 3 – Pharmacy professionals must communicate effectively.
• Standard 5 – Pharmacy professionals must use their professional judgement.
• Standard 8 – Pharmacy professionals must speak up when they have concerns.

Case Summary

Original Case Document