Community Pharmacist Warned After Dispensing Errors Involving Child Patient Lead to Hospitalization

Date of Decision: July 3, 2025

Registrant's Role: Pharmacist

Allegations:

• Supplied incorrect medication to a child without adequate checking.
• Supplied medication unsuitable for a child’s age and dosage requirements, leading to hospitalization.
• Repeated dispensing errors in July 2022 and May 2023, indicating a lack of due diligence and insight.
• Failed to involve or communicate effectively with other staff and the patient’s mother.
• Delegated communication to an unqualified apprentice.

Outcome: Warning issued

GPhC Standards Breached:

• Standard 2 – Must work in partnership with others
• Standard 3 – Must communicate effectively
• Standard 5 – Must use their professional judgement
• Standard 9 – Must demonstrate leadership

Case Summary

Allegations
The General Pharmaceutical Council (GPhC) investigated a series of serious professional failings by the registrant, a pharmacist who was the Responsible Pharmacist at a community pharmacy in Warrington. The investigation was prompted by three separate medication incidents that occurred between March 2022 and May 2023, with the most serious involving the incorrect supply of medication to a child.

In March 2022, the registrant supplied medication for a child without performing adequate checks. The error led to the child receiving medication that was not only inappropriate for their age but also dosed at a level eight times higher than the minimal therapeutic dose for a child. This led to the child becoming unwell and requiring hospital admission.

Despite the gravity of this initial error, the registrant made further similar dispensing errors in July 2022 and again in May 2023. These incidents highlighted an ongoing failure to adhere to essential checking protocols, suggesting a pattern of carelessness and a concerning lack of professional insight.

Additionally, the registrant failed to involve available staff in the checking process and chose to carry out self-checking. Communication was also poor; notably, the registrant failed to confirm with the mother of the child that the dosage instructions were understood and delegated the responsibility of discussing medication to an unqualified apprentice.

Findings
The GPhC’s Investigating Committee concluded that the registrant’s conduct represented a clear breach of professional standards. The repeated nature of the dispensing errors and the serious consequences of the first incident revealed a troubling absence of vigilance and professional development following a serious event. Rather than demonstrating improvement or heightened caution, the registrant repeated the same fundamental mistakes, which could have endangered patient safety.

In terms of specific standards breached:

• Standard 2 was compromised by the registrant’s failure to consult with colleagues or involve other trained staff in the checking process, even when they were present. This failure undermined the safeguarding of patients, especially vulnerable individuals like children.
• Standard 3 was breached due to ineffective communication with the child’s mother, particularly the failure to confirm understanding of dosage instructions.
• Standard 5 was not met, as the registrant did not demonstrate sound professional judgment, failed to recognize limitations in their own competence, and repeated serious errors without adequate remediation.
• Standard 9 was violated when the registrant asked an unqualified apprentice to speak to a patient’s parent, despite their lack of training or competence in handling such communication.

GPhC Determination on Impairment
The Committee found that while the registrant’s conduct did not necessitate removal from the register, it did merit a formal warning. The determination emphasized the critical role of clinical checking in the pharmacy profession and recognized the registrant’s actions as falling short of acceptable standards.

The panel considered that, although the registrant did not intend to cause harm, their carelessness significantly undermined public confidence in pharmacy services and exposed patients to risk. It was also noted that there appeared to be a lack of insight, as evidenced by the continuation of unsafe practices after the March 2022 incident.

Sanction
The GPhC issued a warning, noting:

“Ensuring the correct medication is supplied is of fundamental importance to pharmacy professionals and patients are placed at risk of harm when checks are inadequate. [The registrant] is warned that, in future, he must ensure that all medications are adequately clinically checked before dispensing.”

This warning will remain visible on the GPhC public register for 12 months. The Committee underscored that any recurrence of similar behavior would likely prompt further regulatory intervention, potentially with more severe consequences.

Key Learning Points for Pharmacy Professionals

1. Always perform clinical and legal checks before dispensing medications, especially for vulnerable populations like children. The dosage and suitability of medications must be meticulously assessed.
2. Never rely solely on self-checking when other qualified personnel are available. Shared responsibility and peer verification are vital safeguards in pharmacy practice.
3. Effective communication with patients and caregivers is essential. Pharmacists must ensure that instructions are fully understood and clearly explained, especially in pediatric cases.
4. Only delegate tasks to appropriately trained personnel. Pharmacists must oversee and take full responsibility for all communications and clinical decisions made in the pharmacy.
5. Learn from errors. Serious incidents should serve as catalysts for reflection, training, and improved practice. Repeating mistakes after a serious event indicates a lack of insight and professionalism.

This case illustrates the potentially grave consequences of dispensing errors and reinforces the fundamental duties of diligence, communication, and leadership in pharmacy practice.

Original Case Document

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