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Pharmacist Removed from Register for Unsafe Storage and Intended Reuse of Out-of-Date Medicines

Date of Decision: December 16, 2019

Allegations: Asked an individual to store pharmaceutical waste (DOOP bins) in his garage. Requested that the same individual compile inventories of out-of-date medicines. Intended to reuse medications that were expired. Failed to ensure safe and effective storage of medication by instructing untrained individuals to handle pharmaceutical waste.

Outcome: Removal from the GPhC register

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Pharmacist Suspended for Assisting Suicide Using Stolen Medicines

Date of Decision: December 4, 2018

Allegations: Conviction for criminal offences involving theft of prescription medicines. Assisting in the suicide of a vulnerable individual using stolen controlled drugs. Breach of legal and professional obligations relating to the handling and use of controlled substances.

Outcome: Suspension from the register for 12 months

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Pharmacist Suspended for Forging Gas Safety Certificate in Private Property Sale

Date of Decision: January 16, 2019

Allegations: Convicted of forgery after creating a false gas safety certificate during the sale of a private business property. Forged the signature of a gas engineer and submitted the document as part of a property sale. The forged certificate was later discovered to be invalid, and the boilers were deemed unsafe. The engineer whose name was used was wrongly implicated and suspended from work.

Outcome: 8-month suspension from the GPhC register

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Pharmacist Warned for Failing to Safeguard High-Risk Medicines in Online Dispensing Scheme

Date of Decision: May 19, 2025

Allegations: Oversaw the dispensing of over 380 private prescriptions for high-risk medicines (e.g. opioids, Z-drugs) in under two months. Failed to identify or manage risks associated with online prescribing from a third-party company. Did not confirm the appropriateness of the prescribing process, or whether repeat and high-dose prescriptions were being monitored. Did not ensure adequate SOPs or governance procedures were in place. Admitted he was unaware of GPhC guidance relevant to distance selling.

Outcome: Formal warning issued

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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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