Locum Pharmacist Removed from GPhC Register After Stealing and Injecting Midazolam at Work

Date of Decision: September 4, 2025

Registrant's Role: Pharmacist

Allegations:

Removed a quantity of Midazolam from the pharmacy without legal authority, prescription, or payment.
Injected Midazolam into his own body while on duty.
Acted dishonestly in taking the Midazolam without permission or authority.
Practised as a pharmacist while unfit due to drug use.
Had underlying medical conditions relevant to fitness to practise.

Outcome: Removal from the register

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 5 – Use professional judgement
Standard 6 – Behave in a professional manner
Standard 9 – Demonstrate leadership

Case Summary

Allegations

This case involved a locum pharmacist who was found to have engaged in serious misconduct while on duty at Tiffenbergs Chemist in Liverpool. The core of the allegations centred on his unlawful handling and self-administration of Midazolam, a Schedule 3 controlled drug, which he removed from pharmacy stock and injected into himself during working hours on 15 September 2022.

He was observed acting suspiciously around drawers containing controlled drugs and repeatedly visiting the toilet, where rustling sounds were heard. Colleagues later discovered paraphernalia in the toilet bin, including a ripped Midazolam box, a broken ampoule, and tissues with blood on them. Subsequently, he was seen slurring his speech, unable to focus, and physically unsteady—yet he returned to the dispensary and attempted to resume professional duties.

The allegations further included that he had acted dishonestly by taking Midazolam without prescription or authority, knowing that he lacked legal grounds. The pharmacist was also alleged to have practised while impaired by drugs and to be suffering from medical conditions relevant to his fitness to practise.

Findings

The Fitness to Practise Committee found all factual allegations proven. Witness accounts described a stark transformation in the registrant’s condition, from normal behaviour to clear signs of drug intoxication: slurred speech, disorientation, and impaired motor control. One witness described him staring “transfixed” at a box of Evacal and being visibly unable to perform basic tasks.

There was compelling evidence of the registrant’s removal and use of Midazolam, including physical evidence and corroborated testimony. The Committee concluded that his actions were dishonest and intentional, especially given that Midazolam is a sedative with known central nervous system depressant effects—well understood by any trained pharmacist.

A particularly aggravating detail was the discovery of a BD Microfine syringe not stocked by the pharmacy, implying premeditation.

The registrant provided a written apology, admitting to the general truth of the allegations but claiming no memory of the event due to the effects of the drug. However, this was not deemed a sufficient demonstration of insight or accountability.

GPhC Determination on Impairment

The Committee considered the conduct to be serious misconduct, both in terms of professional dereliction and moral failing. It concluded that the registrant was impaired due to both misconduct and health grounds.

The registrant’s actions breached key professional standards—most notably his failure to provide safe, patient-centred care; his poor judgement; and his unprofessional behaviour. The Committee was particularly concerned by the absence of insight or remediation. The registrant had neither undertaken any rehabilitative steps nor demonstrated a meaningful understanding of the severity of his actions.

Though the misconduct occurred in a single incident, it was described as fundamentally incompatible with professional pharmacy practice. The Committee noted that the registrant’s lack of insight and reflection increased the likelihood of repetition.

“The lack of insight into the conduct, the underlying causes of it and any action to remediate it, means that there is a high risk of the conduct being repeated.”

Sanction

Given the serious breach of standards, the dishonesty involved, and the potential risk to patient and public safety, the Committee determined that removal from the register was the only appropriate sanction.

Although the GPhC case presenter initially proposed a 12-month suspension with a review, the Committee considered this insufficient. The pharmacist’s lack of engagement, remediation, and insight led the panel to determine that a suspension would not serve to uphold public confidence or safeguard the profession’s integrity.

Moreover, the Committee emphasized that patient safety and public confidence must take precedence over personal mitigating factors, even in cases involving health issues:

“The Committee concluded that the Registrant’s conduct was fundamentally incompatible with him remaining on the register.”

An interim suspension was imposed to prevent the registrant from practising while the appeal period lapsed.

Key Learning Points for Pharmacy Professionals

Handling of Controlled Drugs: The case underscores the critical responsibility pharmacists have in the secure and lawful handling of controlled drugs. Any unauthorised removal—especially for self-administration—is a grave breach.
Practising While Impaired: Pharmacists must never practise when their cognitive or physical capacities are compromised. Administering a sedative such as Midazolam and continuing to work placed patients and colleagues at significant risk.
Dishonesty and Professional Integrity: Dishonesty—even when tied to health or personal crises—is treated with utmost seriousness by regulators. This case demonstrates that dishonesty, particularly involving drugs, is often viewed as irredeemable without clear, demonstrable remediation.
Insight and Remediation: Professionals facing health or misconduct allegations must show genuine understanding and take proactive steps to remediate. A lack of insight or refusal to engage with regulatory processes can lead to removal even in single-incident cases.
Leadership and Accountability: The registrant’s failure to uphold leadership expectations—particularly as the senior clinical professional on-site—was a key factor in the panel’s decision. Pharmacists must model professionalism, especially under pressure.

This case is a sobering reminder that patient safety and public trust are paramount. Pharmacy professionals must maintain vigilance not only in clinical decision-making but also in personal conduct and ethical integrity.

Original Case Document

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