Methotrexate Dispensing Error Contributes to Patient’s Death: GPhC Issues Warning to Pharmacist
Date of Decision: October 12, 2026
Registrant's Role: Pharmacist
Allegations:
- Supplying 98 methotrexate tablets instead of the prescribed 14, with the intended weekly regimen erroneously dispensed for daily administration.
- Failing to identify the error during calculation, dispensing or the final accuracy check.
- Failing to counsel the patient on safe methotrexate use, including the specified weekly administration day and the potentially fatal consequences of overdose.
- Failing to check whether the patient had an alert card or methotrexate booklet, as stipulated in the pharmacy’s standard operating procedure.
- Failing to adequately consider the patient’s age, titrating regimen, monitoring requirements and unusually large quantity supplied.
- Failing to contact the prescriber to clarify the supply.
- An inadequate checking process, including failure to use the separately prescribed weekly folic acid regimen as an opportunity to verify the methotrexate schedule.
Outcome: Warning issued
GPhC Standards Breached:
- Standard 1 – Pharmacy professionals must provide person centred care.
- Standard 2 – Pharmacy professionals must work in partnership with others.
- Standard 5 – Pharmacy professionals must demonstrate leadership (see "Editor's note" for more details)
Case Summary
Allegations
An elderly patient presented a handwritten prescription from a dermatologist for methotrexate and folic acid. Methotrexate was intended to be taken once weekly, on Mondays, with the dose increased each week. Folic acid was prescribed for Fridays. This combination of a specified administration day and an incremental regimen required careful interpretation, calculation and explanation to the patient.
On 17 January 2025, the registrant was working as the locum Responsible Pharmacist and the only pharmacist at the pharmacy, assisted by a dispenser. The prescription was for 14 methotrexate tablets. Instead, the patient received 98 tablets, with the weekly regimen erroneously dispensed for daily administration.
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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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