GPhC Warning After Pharmacist Failed to Verify Patient Identity Before Supervised Buprenorphine Supply
Date of Decision: July 28, 2026
Registrant's Role: Pharmacist
Allegations:
- Before dispensing and supervising the consumption of a controlled drug prescription for buprenorphine 12 mg tablets, the registrant failed to carry out sufficient checks to confirm that the person collecting and receiving the medication was the correct patient.
- In doing so, the registrant failed to follow the pharmacy’s Standard Operating Procedure entitled “Dispensing prescriptions for CDs”.
Outcome: Warning
GPhC Standards Breached:
- Standard 3 – Communicate effectively
- Standard 5 – Use professional judgement
- Standard 9 – Demonstrate leadership
Case Summary
Allegations
This case arose from the supply and supervised consumption of buprenorphine 12 mg tablets under a controlled drug prescription. Buprenorphine was identified in the determination as a Schedule 3 controlled drug. The registrant was responsible not only for dispensing the medicine but also for supervising its consumption.
Before carrying out these activities, the registrant was required to establish that the person presenting at the pharmacy was the patient for whom the prescription had been issued. The Committee found that the checks undertaken were insufficient. As a result, the registrant did not adequately confirm that the individual collecting and consuming the medication was the correct patient.
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- Full allegations considered by the GPhC
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- Key professional learning points
Original Case Document
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