Pharmacist Given Further Suspension Over Controlled Drug Governance, RP Log Failings and Lack of Insight

Date of Decision: June 24, 2026

Registrant's Role: Pharmacist

Allegations:

Failed to put measures in place to maintain supervision and the safe running of the pharmacy while off sick from 31 May 2022 until an unknown date in July 2022.
Failed to ensure the Responsible Pharmacist log was adequately maintained, including: The RP log showed the registrant signed in as RP between 1 June 2022 and 20 July 2022 while off sick and not working at the pharmacy; The RP log did not show the correct RP on duty during that period.
Failed to put sufficient pharmacy records in place in line with safe-running guidance, namely: No near-miss log; No Information Commissioner’s Office registration up to 21 July 2022.
Failed to store Controlled Drugs in a locked cabinet by keeping the following in a dispensary drawer in August 2022: Three ampoules of morphine sulphate; Five Butec patches; Around 29 boxes of buprenorphine tablets.
Failed to store Controlled Drugs in a locked cabinet by leaving the following on a pharmacy bench in August 2022: A glass measure containing Physeptone solution; A 500ml bottle of Physeptone solution.
Failed to keep accurate balance checks of Controlled Drug Physeptone SF solution to account for any overage and minimise the risk of loss or diversion.
Failed to keep Controlled Drug register entries accurate and up to date, including: Morphine showing a zero balance on 12 June 2020 with no further updates by the inspection on 8 August 2022; Zomorph showing a balance of 16 capsules on 1 June 2022 when none were found in the CD cabinet on 8 August 2022; Zomorph capsules obtained in 2020 not entered into the CD register.
Failed to ensure pharmacy procedures, systems or controls were sufficient to account for: The large amount of codeine linctus, including Galenphol and Galcodeine, purchased by the pharmacy; The legitimate and appropriate supply of codeine linctus.
Between 8 August 2022 and 31 August 2023: Failed to ensure CD registers were accurate and up to date for Zomorph and oxycodone; Failed to ensure patient-returned CDs were accurately recorded and disposed of.

Outcome: Further suspension order for three months with review.

GPhC Standards Breached:

Standard 1 – Pharmacy professionals must provide person-centred care.
Standard 5 – Pharmacy professionals must use their professional judgement.
Standard 6 – Pharmacy professionals must behave in a professional manner.
Standard 7 – Pharmacy professionals must respect and maintain a person’s confidentiality and privacy.
Standard 9 – Pharmacy professionals must demonstrate leadership.

Case Summary

Allegations

This case concerned serious governance, supervision and Controlled Drug management failures at a community pharmacy where the registrant held senior responsibilities as both Superintendent Pharmacist and Responsible Pharmacist. The allegations arose from inspections in July 2022, August 2022 and August 2023, and focused on whether the registrant had maintained adequate systems to ensure the safe and lawful running of the pharmacy.

The first major issue was the safe running of the pharmacy while the registrant was off sick following a serious health event. Although the panel accepted that the registrant had been unwell, it found that he still retained responsibility for ensuring appropriate arrangements were in place. The Responsible Pharmacist log showed the registrant as signed in as RP throughout a period when he was not physically present or working at the pharmacy. The correct RP details were not recorded, and a locum pack was not available to support the locum pharmacist who was working at the time.

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