Your guide to Pharmacy Law and Ethics
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:
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.
Date of Decision: September 4, 2025
Allegations: The registrant, acting as Responsible Pharmacist, incorrectly checked and signed off medication. A box of Atenolol 100mg tablets was incorrectly labelled and dispensed as Allopurinol 100mg. The error led to the patient consuming the wrong medication and suffering bradycardia.
Outcome: Warning issued, to remain on the register for 12 months.
Date of Decision: September 4, 2025
Allegations: Inappropriately accessed the medical records of her ex-husband on at least five occasions without clinical justification. Accessed the medical records of family members based only on verbal consent. Breached NHS and employer data protection policies. Received a final written warning from her NHS employer. Accepted a formal police caution for two offences under the Data Protection Act 2018.
Outcome: Warning issued by the GPhC Investigating Committee
Date of Decision: September 2, 2025
Allegations: Unlawful possession of prescription-only medications (including controlled drugs) without valid prescriptions Failure to record transactions of misappropriated medications Abuse of professional position to obtain medication not available to the public without a prescription Failure to report circumstances affecting fitness to practise to the regulator Convictions for possession of Class C controlled drugs (Pregabalin, Diazepam) Conviction for theft of medications belonging to his employer
Outcome: 9-month suspension from the register
Date of Decision: May 7, 2020
Allegations: Attended work as a Responsible Pharmacist while unfit and/or under the influence of cocaine Admitted to having consumed cocaine to colleagues Historical use of cocaine on other occasions between January 2017 and the date in question Failed to cooperate with the GPhC investigation by refusing drug tests
Outcome: Suspension extended for 6 months
Date of Decision: August 28, 2025
Allegations: Administered Zostavax (a shingles vaccine intended for adults) to a 2-year-old child instead of the prescribed Varivax (chickenpox vaccine) Failed to check the child’s name and date of birth before administering the vaccine Did not obtain informed consent from the child’s mother Did not explain the risks associated with the vaccine Administered a vaccine not covered by a Patient Group Direction (PGD) Inserted the same needle multiple times into the child's arm during vaccination Failed to review the relevant PGD before the appointment Acted outside his scope of competence (not an independent prescriber and lacked training) Did not make an adequate clinical record of the appointment
Outcome: Suspension – 4 months (with immediate interim suspension)
Date of Decision: August 29, 2025
Allegations: Failed to ensure professional indemnity insurance for two pharmacies over multiple months. Submitted false declarations to the GPhC regarding indemnity arrangements. Dispensed approximately 93 prescription-only medicines (POMs) without insurance cover. Dishonest conduct in knowingly misleading the GPhC on multiple occasions.
Outcome: Suspension – 6 months with review
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.
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
Date of Decision: August 26, 2025
Allegations: Accessing patient medical records of two individuals who were also colleagues at the medical practice pharmacy Sharing this confidential information with two different colleagues Doing so without clinical justification or consent
Outcome: Warning issued by the GPhC Investigating Committee, to remain on the public register for 12 months
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