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:

GPhC suspends Responsible Pharmacist for 3 months after CD register failures and unsafe reuse of returned medicines

Date of Decision: August 14, 2025

Allegations: Between approximately June 2018 and 18 October 2022, failed to maintain any, or any adequate, controlled drug (CD) register entries for CDs received and/or supplied. On or about 18 October 2022, failed to ensure one or more CD registers were kept on the pharmacy premises. On or about 18 October 2022, failed to store CDs securely: CDs were found in unlocked tote bags within the dispensary. Between 19 April 2022 and 5 August 2022, on one or more occasions placed patient-returned medication back into stock for reuse. Between 19 April 2022 and 5 August 2022, on one or more occasions instructed a colleague to use contents of unmarked dosette boxes to prepare new dosette boxes. Around 18 May 2023, failed to ensure the multicompartment compliance pack (MDS) service was safe: packs were stored unsealed while awaiting the accuracy check. Around 18 May 2023, did not monitor and record temperatures for all medicines fridges, so could not assure appropriate cold-chain storage. Around 18 May 2023, did not ensure measuring equipment used in the dispensary was clean and hygienic.

Outcome: 3-month suspension

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Warning Issued Over Online Dispensing Failures: Key Safeguards Ignored by Superintendent Pharmacist

Date of Decision: August 13, 2025

Allegations: Failed to carry out sufficient due diligence before dispensing for an online prescribing service. Did not verify the regulatory status or safety protocols of the prescribing service. Did not ensure the existence of procedures for prescribing, clinical monitoring, or managing overprescribing. Failed to confirm processes for verifying patient identity and medical history. Dispensed without access to consultation notes or completed patient questionnaires. Did not assess patient consent regarding sharing information with GPs. Failed to conduct risk assessments and audits of the dispensing practice. Dispensed medicines without confirming clinical appropriateness or monitoring.

Outcome: Warning published on the register for 12 months

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12-Month Suspension for NHS Pharmacist Following Findings of Boundary Breaches and Sexual Misconduct Allegations

Date of Decision: August 8, 2025

Allegations: Unsolicited hugging of multiple female colleagues between 2015 and 2021, including hugging without permission, from behind, and for prolonged periods. Removing a colleague’s bleep in order to initiate physical contact. Sending inappropriate social media messages to colleagues, including comments such as “wife material,” “wit woo,” and other remarks on physical appearance. Continued physical contact despite formal advice from employer to desist. Some behaviours found to be sexually motivated, particularly towards one colleague, involving back rubbing in the bra strap area. Transgression of proper professional boundaries.

Outcome: 12-month suspension (with interim suspension already in effect)

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Hospital Lead Pharmacy Technician Removed from Register After Conviction for Attempted Sexual Communication with a Child and Dishonest Declaration to GPhC

Date of Decision: August 8, 2025

Allegations: Convicted of attempting to engage in sexual communication with a person believed to be a 13-year-old girl, contrary to Section 15(1) of the Sexual Offences Act 2003, between 22 January 2023 and 15 March 2023. Submitted an annual declaration to the GPhC on 14 January 2024 incorrectly stating “No” to being under investigation by any regulatory body or criminal enforcement authority, despite being under police investigation at the time. Conduct in making the false declaration was dishonest and/or lacked integrity.

Outcome: Removal from the GPhC Register, with immediate interim suspension pending the decision taking effect.

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Allcures Pharmacist Warned for Controlled Drug Recording Breaches and Dispensing Error Involving Medikinet and Tranquilyn

Date of Decision: August 7, 2025

Allegations: Dispensing a mixture of Medikinet 5mg tablets and Tranquilyn 5mg tablets against a prescription for Medikinet 5mg tablets, without an approved shortage protocol in place. Failing to make accurate records in the controlled drug register. Retrospectively altering entries in the controlled drug register for Tranquilyn 5mg tablets.

Outcome: Warning published on the register for 12 months.

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Pharmacist Warned for Dishonest Pharmacy Quality Scheme (PQS) Claim

Date of Decision: August 7, 2025

Allegations: Submitted an NHS Pharmacy Quality Scheme (PQS) claim for 2021/2022 confirming all eligibility criteria had been met, including required training, when this was not the case. Stated to head office management that training evidence was left at home, when aware no such evidence existed as the required training had not been completed. Knowingly acted dishonestly and lacked integrity by making the claim and misleading management.

Outcome: Warning (published for 12 months on the GPhC register)

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Locum Pharmacist Struck Off After Dangerous Methadone Dispensing Error and Dishonesty

Date of Decision: May 13, 2019

Allegations: Supplied methadone to a patient without a prescription or clinical justification Failed to provide clinical advice or seek emergency medical treatment after the error Attempted to conceal the error and provided dishonest accounts to colleagues Failed to declare a prior criminal conviction to the GPhC Engaged in dishonest conduct by concealing the conviction during applications for registration

Outcome: Removal from the register

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