Colchicine Dispensing Error Leads to GPhC Warning for Retail Pharmacist
Date of Decision: September 18, 2025
Registrant's Role: Pharmacist
Allegations:
- Dispensing Colchicine 500mcg tablets with incorrect dosage/frequency instructions.
- Failure to provide patient counselling.
- Failure to supply a patient information leaflet with the medication.
Outcome: Warning issued by the GPhC Investigating Committee.
GPhC Standards Breached:
- Standard 1 – Pharmacy professionals must provide person-centred care.
- Standard 3 – Pharmacy professionals must communicate effectively.
Case Summary
Allegations
The case centres around a significant dispensing error made by the registrant while acting as the Responsible Pharmacist in a retail pharmacy in Harlow on 26 January 2025. The medication in question was Colchicine 500mcg tablets, a drug with a narrow therapeutic index, commonly used to treat acute gout and familial Mediterranean fever. The registrant erroneously supplied 12 tablets to a patient (Patient A) with dosage instructions that would have resulted in double the prescribed daily dose. Compounding this issue, the medication was dispensed without any accompanying counselling and no patient information leaflet was included in the supply.
These combined errors posed a serious risk of patient harm. Colchicine, in excessive doses, can lead to toxicity, necessitating emergency medical intervention. Had the patient followed the dosage instructions as labeled, it is likely they would have had to attend A&E, illustrating the gravity of the error.
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- Full allegations considered by the GPhC/PSNI
- Panel findings and reasoning
- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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