GPhC Warning After Repeated Controlled Drug Management Failures and Dispensing from an Expired Prescription
Date of Decision: September 17, 2026
Registrant's Role: Pharmacist
Allegations:
- Between August 2024 and February 2025, while acting regularly as the Responsible Pharmacist and Pharmacy Manager at a branch of Well Pharmacy, the registrant was associated with repeated deficiencies in controlled drug management identified through pharmacy audits.
- Out-of-date and returned medication had not been destroyed.
- Controlled drug balances showed discrepancies, or required balance checks had not been carried out.
- Keys to the controlled drug safe were left unsecured.
- Controlled drugs were left unsecured within the pharmacy.
- One patient was dispensed MST 5 mg tablets from an expired prescription on more than one occasion.
- The conduct was considered to represent a failure to discharge adequately the responsibilities associated with the Responsible Pharmacist role, particularly in relation to the safe management of controlled drugs.
Outcome: Warning issued
GPhC Standards Breached:
- Standard 3 – Pharmacy professionals must work in partnership with others, which includes using records of care provided.
- Standard 8 – Pharmacy professionals must speak up when they have concerns or when things go wrong, which includes escalating when they feel that a working environment has become unsafe to prevent ongoing issues.
- Standard 9 – Pharmacy professionals must demonstrate leadership, which includes doing everything possible to keep risks as low as possible.
Case Summary
Allegations
This case concerned the management of controlled drugs and the wider responsibilities attached to the roles of Responsible Pharmacist and Pharmacy Manager. The registrant was described as a regular Responsible Pharmacist and Pharmacy Manager at a branch of Well Pharmacy between August 2024 and February 2025. During that period, audits identified recurring problems with the management of controlled drugs rather than a single isolated incident.
The concerns covered several important aspects of controlled drug governance. The determination records that out-of-date and returned medicines had not been destroyed. It also refers to discrepancies in controlled drug balances and occasions where checks had not been carried out. These issues are particularly significant in a pharmacy setting because controlled drug records, stock reconciliation and appropriate disposal procedures provide important safeguards against errors, loss, misuse and diversion.
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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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