Pharmacist Given 18-Month Conditional Registration for Mismanagement of Controlled Drugs and Pharmacy Standards

The registrant, a pharmacist and pharmacy owner, was responsible for multiple failings in the management of Controlled Drugs and general pharmacy standards over a 17-month period. These included:

• Inaccurate CD registers (e.g., balances for methadone, Zomorph, and Sevredol not matching stock).
• No CD register entries for extended periods.
• Leaving bottles of methadone out while serving patients.
• Cluttered, unhygienic pharmacy premises and unremoved expired medicines.
• Poor or nonexistent balance checks—some as infrequent as once every five or six months.

Despite previous removal from the register in 2010 for serious misconduct involving the over-the-counter sale of codeine linctus, the registrant failed to adhere to expected professional standards again.

Findings

The Committee found:

• The registrant admitted all allegations except one, which was withdrawn.
• Repeated breaches of CD regulations, with serious lapses in hygiene and safety.
• A pattern of delayed or missing record entries, and failure to separate expired drugs from stock.
• Inadequate balance checks, particularly concerning given previous fitness to practise history.

Although no actual patient harm occurred, the Committee noted:

“There was potential for serious harm to the public… public confidence in the profession will have been undermined by the registrant’s mismanagement.”

The registrant showed some insight and made late-stage improvements, including hiring staff, implementing SOPs, and starting CPD. However:

• Remediation was not fully in place, and key safeguards were still missing.
• He had not undertaken specific CPD on CD management, despite repeated failings in this area.
• His evidence was “vague and confused,” and improvements were “not sustained over time.”

GPhC Determination on Impairment

The Committee found that the registrant’s fitness to practise was currently impaired, because:

• There remained a risk of repetition due to lack of robust processes.
• The registrant had not demonstrated long-term, sustainable change.
• There was a need to uphold public confidence and standards within the profession.

“While the registrant has some insight, the documentary evidence does not fully demonstrate that his actions match his intentions.”

The Committee noted the registrant’s remorse and developing insight, but concluded more time and supervision were needed to protect the public.

Sanction

An 18-month conditional registration was imposed with the following key requirements:

• The registrant must undergo remote supervision by a registered pharmacist.
• Submit a personal development plan and undertake training in safe CD management.
• Provide quarterly supervisor reports on practice and CD register accuracy.
• Notify all current and potential employers and submit evidence of this to the GPhC.
• Reflective writing on the impact of his misconduct and analysis of changes implemented.

“Suspension would be disproportionate… the conditions provide an opportunity for the registrant to demonstrate safe practice and sustained improvement.”

The Committee also imposed interim conditions pending any appeal, citing the importance of public protection.

Key Learning Points for Pharmacy Professionals

1. Controlled Drugs must be safeguarded through accurate, timely records – Lapses in CD management pose a direct risk to patient safety and public trust.
2. Hygiene and stock control are part of professional standards – Untidy premises and expired stock reflect poorly on the profession and can trigger regulatory action.
3. Sustained improvement is essential – Isolated improvements or short-term efforts are not enough if past misconduct was serious or repeated.
4. Insight requires practical changes – Intentions must be matched by robust systems, regular checks, and continuing professional development.
5. Previous misconduct can impact future decisions – A past record of erasure or suspension increases the seriousness of any further failings.

Conclusion

This case demonstrates how ongoing failings in the management of Controlled Drugs and pharmacy premises—especially by a superintendent pharmacist—can lead to substantial regulatory restrictions. The 18-month conditional registration reflects the seriousness of the risk while giving the registrant a final opportunity to show sustained reform, supported by supervision and structured CPD.