Fitness to Practise Cases

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This archive contains General Pharmaceutical Council (GPhC) Fitness to Practise (FtP) case summaries, detailing regulatory decisions affecting pharmacy professionals in the UK.

Each case provides insight into professional misconduct, errors, and ethical breaches that led to sanctions such as suspension, removal, or warnings. These summaries are valuable for:

  • Pharmacists & Pharmacy Technicians – to understand common regulatory pitfalls.
  • Employers & HR Teams – to learn about professional accountability and compliance.
  • Pharmacy Students – to prepare for real-world ethical challenges in pharmacy practice.

How to use this case summary database:

  • Search for specific cases using the search box above. You can search by keyword (e.g., "controlled drugs," "dishonesty," "suspension"), by sanction type (suspension, removal, warning) or issue type (dishonesty, prescribing errors, controlled drugs, etc.)
  • Alternatively, scroll down to browse the latest FtP case summaries.

Why it matters:

The decisions in these cases shape the legal and ethical landscape of pharmacy practice. Staying informed can help pharmacy professionals avoid similar mistakes and maintain high professional standards.

Latest FtP case summaries:

Warning Issued for Pharmacist Over Excessive Codeine and Phenergan Orders Without Oversight

Date of Decision: September 11, 2025

Allegations: Excessive and unaccounted ordering of Codeine Linctus and Phenergan Elixir. Failure to maintain oversight of pharmacy systems related to stock ordering and medication safety. Breaches in secure storage of dispensed medication and patient information. Improper maintenance of controlled drug records. Inaccurate responsible pharmacist log. Inappropriate use of NHS Smartcards by staff.

Outcome: Warning issued and published on the register for 12 months.

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Pharmacist Suspension Expires after Illegally Accessing Colleague’s Medical Records and Making Inappropriate Comments

Date of Decision: September 11, 2025

Allegations: On 17 February 2022, the registrant accessed a colleague's medical records via Evolve without consent or clinical justification. The registrant used sensitive information obtained from those records to make inappropriate and offensive comments to the colleague, causing distress.

Outcome: Suspension Order (3 months) – Fitness to Practise Found No Longer Impaired; Suspension to Expire Without Further Action

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Locum Pharmacist Removed from GPhC Register After Stealing and Injecting Midazolam at Work

Date of Decision: September 4, 2025

Allegations: Removed a quantity of Midazolam from the pharmacy without legal authority, prescription, or payment. Injected Midazolam into his own body while on duty. Acted dishonestly in taking the Midazolam without permission or authority. Practised as a pharmacist while unfit due to drug use. Had underlying medical conditions relevant to fitness to practise.

Outcome: Removal from the register

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Responsible Pharmacist Issues Wrong Medication: Allopurinol-Atenolol Mix-Up Leads to Patient Harm

Date of Decision: September 4, 2025

Allegations: The registrant, acting as Responsible Pharmacist, incorrectly checked and signed off medication. A box of Atenolol 100mg tablets was incorrectly labelled and dispensed as Allopurinol 100mg. The error led to the patient consuming the wrong medication and suffering bradycardia.

Outcome: Warning issued, to remain on the register for 12 months.

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Pharmacist Warned for Repeated Data Breach of Ex-Husband’s Medical Records

Date of Decision: September 4, 2025

Allegations: Inappropriately accessed the medical records of her ex-husband on at least five occasions without clinical justification. Accessed the medical records of family members based only on verbal consent. Breached NHS and employer data protection policies. Received a final written warning from her NHS employer. Accepted a formal police caution for two offences under the Data Protection Act 2018.

Outcome: Warning issued by the GPhC Investigating Committee

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NI Pharmacist Suspended for Theft of Controlled Drugs from McKenzie’s Pharmacy

Date of Decision: September 2, 2025

Allegations: Unlawful possession of prescription-only medications (including controlled drugs) without valid prescriptions Failure to record transactions of misappropriated medications Abuse of professional position to obtain medication not available to the public without a prescription Failure to report circumstances affecting fitness to practise to the regulator Convictions for possession of Class C controlled drugs (Pregabalin, Diazepam) Conviction for theft of medications belonging to his employer

Outcome: 9-month suspension from the register

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Locum Pharmacist Suspended After Administering Shingles Vaccine to Child Under Wrong PGD at Well Pharmacy

Date of Decision: August 28, 2025

Allegations: Administered Zostavax (a shingles vaccine intended for adults) to a 2-year-old child instead of the prescribed Varivax (chickenpox vaccine) Failed to check the child’s name and date of birth before administering the vaccine Did not obtain informed consent from the child’s mother Did not explain the risks associated with the vaccine Administered a vaccine not covered by a Patient Group Direction (PGD) Inserted the same needle multiple times into the child's arm during vaccination Failed to review the relevant PGD before the appointment Acted outside his scope of competence (not an independent prescriber and lacked training) Did not make an adequate clinical record of the appointment

Outcome: Suspension – 4 months (with immediate interim suspension)

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Six-Month Suspension for Superintendent Pharmacist After Dishonest Declarations and Uninsured POM Supply

Date of Decision: August 29, 2025

Allegations: Failed to ensure professional indemnity insurance for two pharmacies over multiple months. Submitted false declarations to the GPhC regarding indemnity arrangements. Dispensed approximately 93 prescription-only medicines (POMs) without insurance cover. Dishonest conduct in knowingly misleading the GPhC on multiple occasions.

Outcome: Suspension – 6 months with review

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