Locum Community Pharmacist Suspended for Falling Asleep in the Pharmacy and Intimidating GPhC Investigation Patient

Date of Decision: July 16, 2025

Registrant's Role: Pharmacist

Allegations:

Fell asleep in the dispensary on the morning of 2 July 2022 while acting as Responsible Pharmacist.
Fell asleep in the consultation room on the afternoon of 2 July 2022, leaving the pharmacy unattended and open to the public for over 20 minutes.
Accessed Patient A's address between 2 July 2022 and 31 January 2023 and noted it outside clinical records.
Attended Patient A’s home on 31 January 2023 and attempted to dissuade her from engaging with a GPhC investigation.
Conduct in attending Patient A’s home with intent to dissuade her from cooperation with GPhC investigation demonstrated a lack of integrity.

Outcome: Suspension – one month

GPhC Standards Breached:

Standard 5 – Use professional judgement: Practise only when fit to do so.
Standard 6 – Behave professionally: Maintain appropriate professional boundaries and behave in a way that maintains public trust.
Standard 7 – Respect and maintain confidentiality and privacy.

Case Summary

Allegations

The case revolves around a series of serious professional lapses by the registrant, a pharmacist, while working as the Responsible Pharmacist at Noor Pharmacy in Birmingham. The panel considered a range of misconduct allegations. Chief among these were two episodes of falling asleep while on duty—one in the dispensary in the morning and another in the consultation room in the afternoon of 2 July 2022. These lapses led to the pharmacy being left open and unattended, thereby placing public safety at risk.

Equally troubling was the registrant’s action of accessing and noting down a patient’s address—Patient A—outside of clinical records, which he admitted to doing. Most significantly, on 31 January 2023, he visited Patient A’s home after becoming aware of a formal complaint she made to the GPhC. Though he initially described the visit as coincidental and intended as an apology, the panel concluded that the visit was premeditated with the intention to dissuade her from engaging with the regulatory investigation.

These actions were viewed as a serious breach of professional trust and confidentiality, compounded by an abuse of his privileged access to patient information. The registrant’s conduct was deemed to exhibit a lack of integrity—an essential component of professional behaviour.

Findings

The panel conducted a detailed fact-finding analysis, hearing evidence from Patient A, the registrant, and reviewing video and audio materials. While the registrant admitted some allegations, he contested others. The Committee ultimately found allegations 1 (falling asleep in the dispensary), 2, 3, 4.1, 4.3, and 5 to be proved either through admission or evidence. It found allegation 4.2 (specific statements allegedly made to Patient A) not proven.

The Committee particularly noted the improbability that someone other than the registrant had fallen asleep in the dispensary on the same day, and concluded he had indeed fallen asleep, although he did not recall doing so.

Patient A was considered a credible witness who displayed no malice. Despite some imperfections in her memory of exact wording, her overall testimony was consistent and supported by contemporaneous recordings.

The registrant’s explanation of events shifted over time, which the panel attributed more to incomplete recollection and attempts at contextualising rather than deliberate deceit. Nonetheless, it concluded that he had indeed accessed patient data inappropriately and had purposefully visited the patient’s address in an effort to influence her participation in the investigation.

GPhC Determination on Impairment

The panel deemed the registrant’s actions to constitute misconduct, finding breaches of Standards 5, 6, and 7 of the GPhC’s Standards for Pharmacy Professionals. These included failures in professional judgement, maintaining professional boundaries, and respecting confidentiality.

Despite the misconduct, the panel recognised the registrant’s significant and demonstrable efforts at remediation. He had no prior disciplinary history in over a decade of practice. The panel noted his extensive reflective work, mentoring engagements, and relevant continuing professional development (CPD), such as courses in patient safety, resilience, and conflict resolution. He had undertaken significant shadowing under peer supervision and developed systems to ensure he only practises when fit to do so.

The registrant showed a high degree of insight and remorse, acknowledging in a reflective statement that his actions had risked “compromising the integrity of the healthcare system.” He also acknowledged that patient autonomy had been undermined by his conduct.

The Committee found that while he no longer posed a risk to public safety, his past misconduct had brought the profession into disrepute and breached fundamental professional principles. Therefore, his fitness to practise was currently impaired in the public interest.

Sanction

In deciding the appropriate sanction, the panel considered the gravity of the misconduct, particularly the abuse of privileged information to visit a patient with the intent of dissuading her from cooperating with a professional investigation. This action was seen as especially harmful, even though it was not accompanied by aggression or overt threats.

After weighing the aggravating and mitigating factors, the panel determined that a suspension of one month was appropriate. Aggravating factors included the registrant’s role as the Responsible Pharmacist, the misuse of patient information, and the emotional impact on the patient. Mitigating factors included an otherwise unblemished career, substantial and authentic remediation, health-related context for part of the behaviour, and acceptance of responsibility.

The panel rejected a warning or conditions as insufficient to maintain public confidence in the profession, stating:

“We consider this case so serious that a warning would not suffice to maintain public confidence.”

They emphasized that although the misconduct was serious, the registrant’s ongoing value to the profession and public, paired with his remediation efforts, warranted a short suspension rather than a more severe penalty.

Key Learning Points for Pharmacy Professionals

Maintaining Fitness to Practise: Pharmacy professionals must ensure they are physically and mentally fit to carry out their duties. Working while unfit endangers public safety and undermines professional responsibility.
Confidentiality and Trust: Accessing and misusing patient data—especially for personal motives—constitutes a serious breach of professional trust and GPhC standards.
Maintaining Professional Boundaries: Visiting a patient outside of a clinical context, especially to discuss an active complaint, is highly inappropriate and violates ethical boundaries.
Integrity is Fundamental: A single act that shows a lack of integrity can seriously jeopardise a professional’s standing. Upholding integrity involves not only avoiding misconduct but actively fostering ethical conduct.
Effective Remediation Matters: Demonstrable insight, reflective practice, mentorship, and CPD can significantly influence outcomes. However, remediation cannot erase the seriousness of misconduct in the eyes of the regulator.
Transparency and Cooperation: The registrant’s cooperative attitude, early reflection, and full disclosure to his current employer were viewed favourably.

This case serves as a powerful reminder that professionalism in pharmacy is measured not only by clinical competence but also by behaviour, judgment, and the ability to uphold the public’s trust under pressure.

Original Case Document

The full determination transcript is available to logged in users.