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 Suspended for Unsafe Remote Prescribing of High-Risk Medicines

Date of Decision: August 28, 2025

Allegations: Prescribed over 3,000 high-risk prescriptions through online pharmacies without proper clinical assessments. Relied solely on online questionnaires without face-to-face or virtual consultations. Failed to access GP or specialist records, compromising patient safety. Issued prescriptions for controlled drugs (e.g., opioids, z-drugs) inappropriately and without due consideration of dependence or misuse. Approved repeat prescriptions for patients with signs of drug-seeking behaviour. Failed to refer patients to their GPs or implement safety netting. Demonstrated a transactional approach to prescribing rather than one based on clinical need or UK prescribing guidance.

Outcome: Four-month suspension with a review; immediate interim suspension ordered.

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Pharmacist Sanctioned for Inappropriate and Excessive Codeine and Phenergan Supplies

Date of Decision: August 27, 2025

Allegations: Failure to implement up-to-date SOPs on high-risk opioid medicines. Inappropriate ordering of large quantities of Codeine Linctus and Phenergan Elixir. Lack of systems to monitor and audit ordering, sale, and supply of high-risk medicines. Specific large orders of Codeine Phosphate and Co-codamol without proper oversight.

Outcome: Conditions imposed for 6 months

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NI Superintendent Pharmacist Warned for Widespread Governance Failures at Belfast Pharmacy

Date of Decision: August 28, 2025

Allegations: Failure to maintain the Pharmacy Record at Earlswood Pharmacy under the Medicines Act 1968 and Responsible Pharmacist Regulations. Absence of appropriate and accessible Standard Operating Procedures (SOPs). Lack of verifiable audit trails for delivery of medicinal products. Inadequate maintenance of Controlled Drug (CD) registers. Failure to conduct periodic stock audits of controlled drugs. Absence of a reliable near miss/error recording system. Inadequate record-keeping of extemporaneously prepared unlicensed medicines.

Outcome: Warning

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Superintendent Pharmacist Warned for Failing to Maintain Any CD Registers

Date of Decision: August 26, 2025

Allegations: Failure to maintain a controlled drugs (CD) register while dispensing Schedule 2 controlled drugs. Failure to manage and assess risks associated with controlled drug handling as Superintendent Pharmacist. Breach of statutory responsibilities under the Misuse of Drugs Regulations 2001.

Outcome: Warning issued and published on the GPhC register for 12 months.

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Serious Record-Keeping Failures in Extemporaneous Medicine Manufacturing Lead to Undertakings for Retiring Superintendent Pharmacist

Date of Decision: August 28, 2024

Allegations: Failed to ensure the pharmacy was organised to comply with standards for unlicensed medicine preparation. Allowed unlicensed medicine “The Tonic” to be manufactured and supplied with inadequate manufacturing records (1,511 bottles supplied, only 120 records). Allowed unlicensed products (“Nappy Ointment”, “Hack Cream”, “Japanese 35% Peppermint Oil Cream”) to be made and sold without any manufacturing records. Failed to ensure SOP for “The Tonic” was adhered to. Failed to have SOPs for other unlicensed medicines listed above.

Outcome: Undertakings accepted in lieu of sanction, including voluntary removal from the register and commitment not to engage in pharmacy or healthcare services.

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NI GP Pharmacist Suspended for Dishonest Prescribing of Tramadol to Family and Friends

Date of Decision: May 15, 2025

Allegations: Issued and dispensed prescriptions for controlled drug (Tramadol/Maxitram) without clinical justification Prescribed medications to individuals with whom she had close personal relationships Manipulated GP clinical systems, including issuing and cancelling prescriptions Used login credentials of other staff members to conceal actions Deleted or altered patient records to hide unauthorised prescribing Acted dishonestly and without integrity over a 2½ year period

Outcome: 9-month suspension from the register

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GP Pharmacist Removed from Register Following Sexual Misconduct Towards Colleague

Date of Decision: August 20, 2025

Allegations: On 9 September 2021, while working at Monkseaton Medical Centre: Touched crotch against a colleague’s shoulder Grabbed colleague’s crotch, placing hand on his penis and rubbing it Simultaneously grabbed or squeezed his own crotch Made the remark, “You're not going to tell anyone are you?” The conduct was alleged and found to be sexually motivated

Outcome: Removal from the Register (with immediate interim suspension)

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Superintendent Pharmacist Issued Warning for Dispensing Generic Medicines against Branded NHS Prescriptions

Date of Decision: August 20, 2025

Allegations: Dispensed generic versions of POMs where branded items were prescribed without a Serious Shortage Protocol (SSP). Dispensed medication of a different strength than prescribed. Labelled medication to reflect what was dispensed rather than what was prescribed. Allegation of dishonesty in relation to the above actions (not proved).

Outcome: Warning

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