Pharmacist Issued Public Warning for Supplying Oramorph Without Prescription

Date of Decision: April 28, 2025

Registrant's Role: Pharmacist

Allegations:

Supplied Oramorph, a Schedule 5 Controlled Drug and prescription-only medicine (POM), to another healthcare professional without a valid prescription.
Failed to meet the legal criteria for an emergency supply and did not create a proper audit trail.
Did not attach a dispensing label or retain a legally required record.

Outcome: Formal warning issued

GPhC Standards Breached:

Standard 5 – Use professional judgement
Standard 6 – Behave in a professional manner
Standard 9 – Demonstrate leadership

Case Summary

The General Medical Council raised a concern regarding the registrant’s conduct. The registrant had:

Supplied Oramorph (morphine sulfate) to a doctor (“Dr A”) for potential use in the doctor’s son’s post-operative pain.
Been told by Dr A that a prescription would be arranged via the son’s GP if the medicine was used.
Supplied the medicine without any prescription in existence or promised by a prescriber.
Made a handwritten note on a piece of paper (now destroyed) as the only record of the supply.
Accepted that no dispensing label was issued for the medication.

Although the medicine was ultimately unused and returned sealed, the registrant’s actions bypassed legal requirements under the Human Medicines Regulations 2012.

Findings

The Investigating Committee found:

The registrant did not have legal authority to make the supply.
The supply did not meet the emergency supply criteria under UK legislation.
There was no audit trail, no dispensing label, and no prescription at the time of supply.

“There was no legal authority to supply a POM in this instance. Furthermore, the supply of a POM requires an audit trail and record, whether it is used or not.”

The Committee accepted that the registrant acted in good faith, but the process he followed was inadequate and fell below expected standards.

GPhC Determination on Impairment

While the registrant’s fitness to practise was not found to be currently impaired, the Committee ruled that a formal warning was appropriate to:

Send a message that such conduct must not be repeated
Maintain public trust in the pharmacy profession
Emphasise that even well-intentioned actions must comply with legal and professional standards

“The registrant’s conduct falls far below the standards expected of a pharmacy professional.”

Sanction

A formal warning was issued, to remain on the GPhC register for 12 months. It reminds all professionals that:

Supplies of POMs must be legally compliant
All dispensing must be recorded and appropriately labelled
Professional judgement includes knowing when not to supply medicine without proper documentation

Key Learning Points for Pharmacy Professionals

Supplying POMs without a valid prescription—even in good faith—is unlawful unless strict emergency supply criteria are met.
Controlled Drugs require full audit trails and labels, regardless of whether the medicine is ultimately used.
Professional judgement must be rooted in legal and ethical frameworks—verbal assurances do not replace prescriptions.
Even single incidents can warrant public warnings if they risk undermining public trust.
Proper documentation and accountability are critical in all supply decisions, particularly involving other healthcare professionals.

Conclusion

This case reinforces that deviation from legal supply procedures—even with good intentions—can result in public disciplinary outcomes. While the registrant was not suspended or found impaired, the GPhC issued a formal warning to uphold professional standards and ensure that all pharmacy professionals understand their legal obligations when handling prescription-only and controlled medicines.

Original Case Document

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