Fitness to Practise Cases

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This archive contains General Pharmaceutical Council (GPhC) Fitness to Practise (FtP) case summaries, detailing regulatory decisions affecting pharmacy professionals in the UK.

Each case provides insight into professional misconduct, errors, and ethical breaches that led to sanctions such as suspension, removal, or warnings. These summaries are valuable for:

  • Pharmacists & Pharmacy Technicians – to understand common regulatory pitfalls.
  • Employers & HR Teams – to learn about professional accountability and compliance.
  • Pharmacy Students – to prepare for real-world ethical challenges in pharmacy practice.

How to use this case summary database:

  • Search for specific cases using the search box above. You can search by keyword (e.g., "controlled drugs," "dishonesty," "suspension"), by sanction type (suspension, removal, warning) or issue type (dishonesty, prescribing errors, controlled drugs, etc.)
  • Alternatively, scroll down to browse the latest FtP case summaries.

Why it matters:

The decisions in these cases shape the legal and ethical landscape of pharmacy practice. Staying informed can help pharmacy professionals avoid similar mistakes and maintain high professional standards.

Latest FtP case summaries:

Pharmacist Warned for Unsafe Partnership with Online Prescribing Service

Date of Decision: May 19, 2025

Allegations: Entered into a contract with a third-party provider to dispense high-risk private prescriptions without conducting adequate safety checks. Dispensed over 380 prescriptions for opioids, Z-drugs, and other misuse-prone medications over a 7-week period. Failed to ensure that prescribing was clinically appropriate or in line with UK guidance. Did not seek adequate indemnity advice or put in place proper SOPs or governance. Was unaware of GPhC distance-selling guidance at the time.

Outcome: Formal warning issued

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Pharmacist Issued Warning for Unsafe Online Prescribing of High-Risk Medicines

Date of Decision: May 19, 2025

Allegations: Approved prescriptions for high-risk medications (e.g. opiates, Z-drugs, propranolol, amitriptyline, weight-loss and asthma medicines) based solely on online questionnaires. Failed to obtain confirmation of diagnoses or medical histories from patients’ GPs or other independent sources. Did not take appropriate steps to safeguard vulnerable patients or consider risks of abuse and dependence. Prescribed to patients who had already received multiple similar prescriptions from other prescribers on the same platform.

Outcome: Formal warning issued

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Pharmacy Technician Suspended for Falsifying Controlled Drug Records

Date of Decision: May 8, 2025

Allegations: Falsified multiple entries in Controlled Drug (CD) registers, including adding fictional stock and altering quantities. Made false entries about CD supplies to patients who had not received medication. Failed to ensure amendments were witnessed, as required by law. Conduct was found to be dishonest, though not for personal gain. Occurred over several months while working under pressure and without support.

Outcome: 3-month suspension

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Specialist Mental Health Pharmacist Allowed to Practise Unrestricted After Successful Remediation

Date of Decision: June 1, 2020

Allegations: Failed to document or communicate a known contraindication (carbamazepine with clozapine) for a patient. Failed to complete medicines reconciliation on hospital admission. Failed to adequately check prescription charts and Mental Health Act forms across multiple patients. Led to unauthorised or incorrect medication administration for several patients. Recorded incorrect BNF code and missed omissions in urgent treatment documentation.

Outcome: Previously subjected to 18-month conditional registration

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Pharmacist Issued Public Warning for Unsafe Independent Prescribing and Self-Medication

Date of Decision: May 8, 2025

Allegations: Carried out independent prescribing and dispensing without informing the pharmacy or obtaining authorisation, over a period of two years. Failed to review clinical histories, document decisions, or notify patients’ GPs. Self-prescribed and supplied himself with a year's worth of medication on three occasions, without exceptional circumstances. Prescribed and supplied a Schedule 3 controlled drug without following legislation and guidance. Did not maintain adequate indemnity insurance for prescribing activities.

Outcome: Formal warning issued

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Pharmacist Suspended for Unlawful Medicine Supply, Drinking on Duty, and Failing Vulnerable Patients

Date of Decision: April 17, 2025

Allegations: Supplied diazepam and codeine-containing medicines to family members without prescriptions. Self-medicated using codeine linctus taken from the pharmacy without authorisation or documentation. Consumed alcohol while on duty in the pharmacy, impairing his judgement. Failed to supply diazepam to a care home resident, later admitting he took the medication home. Told a patient with dementia to call back later because “she wouldn’t remember” anyway.

Outcome: Suspension from the register for 3 months

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Pharmacist Cleared to Practise Following Suspension for Unsafe Online Prescribing Model

Date of Decision: April 28, 2025

Allegations: Approved or prescribed over 36,000 prescriptions for high-risk or monitoring-dependent medicines via UK Meds’ online platform, relying solely on online questionnaires. Failed to perform adequate clinical assessments, access GP records, or request face-to-face consultations. Oversaw the dispensing of nearly 55,000 prescriptions at his pharmacy without sufficient due diligence or risk assessment. Entered into a commercial arrangement with UK Meds despite knowing their prescribing model lacked UK regulatory oversight.

Outcome: No further order. Suspension expired with no ongoing impairment.

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Pharmacist Issued Warning for Unsafe Dispensing Linked to Online Prescribing Platform

Date of Decision: April 28, 2025

Allegations: Dispensed high-risk and prescription-only medicines based on online questionnaires alone, without proper clinical safeguards. Failed to conduct due diligence on the online prescribing service and its prescribers. Did not ensure appropriate risk assessments, GP involvement, or monitoring systems were in place. Failed to properly maintain the private prescriptions register and did not uphold patient safety standards.

Outcome: Formal warning issued

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Pharmacist Issued Public Warning for Supplying Oramorph Without Prescription

Date of Decision: April 28, 2025

Allegations: Supplied Oramorph, a Schedule 5 Controlled Drug and prescription-only medicine (POM), to another healthcare professional without a valid prescription. Failed to meet the legal criteria for an emergency supply and did not create a proper audit trail. Did not attach a dispensing label or retain a legally required record.

Outcome: Formal warning issued

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Pharmacist Suspended Again Over Ongoing Fitness to Practise Concerns Linked to Cocaine Use

Date of Decision: November 26, 2020

Allegations: Attended work as a pharmacist while under the influence of cocaine. Admitted cocaine use on multiple occasions. Failed to cooperate with the GPhC’s health procedures, including refusing to take a drugs test. Engaged with proceedings after nearly two-and-a-half years of disengagement, but failed to provide objective evidence of abstinence.

Outcome: Suspension extended for four months

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