Dishonest Morphine Mismanagement: Pharmacist Suspended for Concealing Controlled Drug Destruction Error

Date of Decision: March 19, 2019

Registrant's Role: Pharmacist

Allegations:

• Failed to report the accidental destruction of a box of 60 x 5mg Morphine Sulphate Tablets (MST) to the Superintendent Pharmacist.
• Failed to enter the receipt of a replacement box of MST into the controlled drug register.
• Engaged in dishonest conduct to conceal the destruction and create a false appearance of register accuracy.
• Made dishonest statements in July and August 2017 denying responsibility for the destruction and ordering of MST.
• Attempted to shift blame onto colleagues by suggesting they might have destroyed the MST.

Outcome: 3-month suspension from the register

GPhC Standards Breached:

• Standard 1.8 – Keep full and accurate records
• Standard 6.1 – Act with honesty and integrity
• Standard 6.5 – Meet accepted standards of personal and professional conduct
• Standard 6.6 – Comply with legal and professional requirements
• Standard 6 (2017) – Behave in a professional manner (including honesty and integrity)
• Standard 8 (2017) – Be open and honest when things go wrong

Case Summary

Allegations

This case centers on a pharmacist who, while employed as a Branch Manager, was found to have engaged in a series of dishonest acts concerning controlled drug (CD) management. The core incident involved the unintentional destruction of a box of 60 Morphine Sulphate Tablets (MST) 5mg, a Schedule 2 controlled drug, during a batch disposal of returned patient medicines. Upon noticing the discrepancy during a stock check, the pharmacist ordered a replacement box but deliberately failed to enter the transaction into the CD register to maintain the appearance of stock balance.

Instead of reporting the error to the Superintendent Pharmacist, as required by standard protocols for CD discrepancies, the registrant concealed the issue. More troublingly, in 2017, during internal investigations, the pharmacist made dishonest statements, both orally and in writing, denying any knowledge of the destruction or replacement of the MST. The registrant even suggested that colleagues may have been responsible, thereby attempting to deflect accountability and implicate innocent professionals.

Findings

The Committee accepted the registrant’s admissions to all factual allegations. Despite some initial uncertainty over who physically destroyed the MST, the registrant accepted overall responsibility and acknowledged his subsequent actions were intended to cover up the error.

The evidence demonstrated that the registrant’s actions were not isolated. They were deliberate, repeated, and spanned a period from 2013 through to 2017. The pharmacist actively misled colleagues and management, submitting written statements and participating in disciplinary meetings with continued dishonesty. It wasn’t until after being confronted with the evidence that the registrant confessed in a late-night phone call, admitting the allegations and expressing remorse.

The Committee highlighted the serious nature of this misconduct. The deliberate falsification of the CD register and the dishonesty during subsequent investigations were seen as significant breaches of professional standards. The pharmacist’s attempt to shift blame onto colleagues was especially concerning, given the potential reputational and emotional harm caused.

GPhC Determination on Impairment

Despite recognising that dishonesty is challenging to remediate, the Committee acknowledged the registrant’s genuine remorse, insight, and efforts at remediation. The registrant provided evidence of continued professional development (CPD), workplace testimonials, and described systemic changes made to his practice to prevent recurrence.

Nonetheless, the Committee emphasized that public confidence in the profession and proper professional standards required a finding of current impairment. They stressed that dishonesty in a professional context undermines the integrity of the entire pharmacy profession. As the determination states:

“The Registrant’s actions will have had a negative impact on public confidence in the pharmacy profession and would bring the profession into disrepute.”

This conclusion was based solely on public interest grounds, as there was no ongoing risk to patient safety identified.

Sanction

The Committee considered various sanctions, including a warning or conditional registration. However, given the seriousness of the dishonesty—particularly the attempt to implicate colleagues—they deemed these inadequate.

Instead, a three-month suspension was imposed. This was considered proportionate, balancing the need to maintain public confidence with the registrant’s otherwise competent practice and substantial remediation. The Committee explicitly decided against removal from the register, acknowledging that the misconduct, while serious, did not warrant permanent exclusion due to the registrant’s high level of insight and lack of ongoing risk.

The suspension was not subject to review, as the Committee concluded there was no additional benefit in further proceedings.

Key Learning Points for Pharmacy Professionals

1. Controlled Drug Handling Requires Rigour: Errors with CDs, especially powerful opioids like MST, must be reported immediately and transparently. Concealing discrepancies undermines trust and breaches legal obligations.
2. Accuracy in Record Keeping is Fundamental: Failing to record receipt of controlled drugs in the CD register is a serious professional breach. Such omissions distort audit trails and could have regulatory or criminal consequences.
3. Dishonesty Can Be Career-Defining: Repeated dishonest acts—even when not involving patient harm—can severely damage a pharmacist’s professional standing. Public confidence hinges on trust.
4. Own Mistakes—Don’t Shift Blame: Attempting to implicate colleagues not only escalates the seriousness of misconduct but also damages professional relationships and could endanger innocent reputations.
5. Insight and Remediation Matter: Demonstrating genuine remorse, reflecting on errors, and implementing concrete changes to practice can influence the outcome of regulatory proceedings. However, they do not erase the need for public accountability.

This case is a stark reminder that pharmacists, as custodians of potent and dangerous medications, must uphold the highest standards of honesty and integrity. Transparent, timely reporting of errors is not just a procedural requirement—it is a professional imperative.

Original Case Document

The full determination transcript is available to logged in users.

Log in or Register for free to access.