Locum Pharmacist Struck Off After Dangerous Methadone Dispensing Error and Dishonesty
Date of Decision: May 13, 2019
Registrant's Role: Pharmacist
Allegations:
- Supplied methadone to a patient without a prescription or clinical justification
- Failed to provide clinical advice or seek emergency medical treatment after the error
- Attempted to conceal the error and provided dishonest accounts to colleagues
- Failed to declare a prior criminal conviction to the GPhC
- Engaged in dishonest conduct by concealing the conviction during applications for registration
Outcome: Removal from the register
GPhC Standards Breached:
- Standard 1 – Provide person-centred care
- Standard 2 – Work in partnership with others
- Standard 3 – Communicate effectively
- Standard 5 – Use professional judgement
- Standard 6 – Behave in a professional manner
- Standard 8 – Speak up when things go wrong
- Standard 9 – Demonstrate leadership
Case Summary
Allegations
The case centres on a serious dispensing error made by the registrant, a locum pharmacist, while working at a community pharmacy. On 23 September 2017, the registrant inadvertently supplied methadone—an opioid substitution therapy medication—to Patient A, who had only attended the pharmacy for treatment of a tickly cough. Critically, Patient A had neither been prescribed methadone nor was there any clinical need for it.
The error occurred when the registrant, acting as the Responsible Pharmacist, confused Patient A with Patient B, who was the actual recipient of the methadone. The registrant supervised Patient A consuming one dose of methadone on-site and provided another bottle for home consumption.
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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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- Detailed findings of fact
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