Pharmacist Placed Under Conditions Following Repeated Governance Failures in Codeine Linctus Supply

The General Pharmaceutical Council (GPhC) reviewed the registrant’s fitness to practise following a history of regulatory breaches related to the supply of codeine linctus, a pharmacy-only medicine known to be misused for its opioid effects.

Concerns were first raised in 2020, when the Medicines and Healthcare products Regulatory Agency (MHRA) flagged unusually high purchasing patterns of codeine linctus at the registrant’s pharmacy. A GPhC inspection in September 2020 found that:

• Over 700 bottles of codeine linctus had been purchased between 2017 and 2019, and a further 240 bottles between January 2020 and July 2020.
• The pharmacy did not maintain adequate records of sales, raising concerns about patient safety.
• Two patients (Person A and Person B) were regularly supplied codeine linctus in circumstances where misuse was suspected.

Findings

The GPhC panel determined that:

• The registrant failed to exercise professional judgment by continuing to supply codeine linctus to two individuals despite clear signs of dependence.
• There were no proper safeguards or oversight to ensure safe and appropriate dispensing.
• The registrant did not have sufficient clinical justification for the continued sale of codeine linctus over an extended period.
• Although the registrant had been previously placed under conditions, they failed to comply with training and reflection requirements, leading to a three-month suspension in November 2024.

A direct quote from the GPhC panel emphasized the severity of the misconduct:

“The registrant demonstrated a sustained failure to provide safe and effective care, placing patients at risk of harm and damaging public confidence in the pharmacy profession.”

While the registrant expressed regret and provided a reflective statement during the latest hearing, the panel found that their insight remained incomplete, particularly in explaining:

• Why the pharmacy was ordering such large quantities of codeine linctus.
• Why the two individuals continued to receive it for an extended period.
• What steps the registrant had taken to prevent similar misconduct in the future.

GPhC Determination on Impairment

The panel ruled that the registrant’s fitness to practise was still impaired, citing:

• Public protection concerns, as there remained a risk of repetition without further remediation.
• Lack of full insight, as key questions about past decisions remained unanswered.
• The need to uphold professional standards, ensuring that pharmacies do not contribute to medicine misuse.

Sanction

The committee imposed a three-month conditions of practice order, determining that:

• The registrant should only work at their own pharmacy under supervision.
• They must not act as a superintendent pharmacist or responsible pharmacist.
• The registrant must complete additional training and provide further evidence of remediation.

Additionally, interim conditions were imposed immediately, preventing unrestricted practice until the conditions take effect or any appeal is resolved.

Key Learning Points for Pharmacy Professionals

1. Medicines liable to misuse require strict oversight – Pharmacists must actively prevent inappropriate or excessive sales of medicines like codeine linctus.
2. Engagement with regulatory requirements is essential – Failing to comply with previous GPhC conditions resulted in further sanctions.
3. Insight and reflection must be thorough – The registrant’s incomplete explanation of past failures contributed to the decision to keep restrictions in place.
4. Patient safety takes priority over customer demand – Continuing to supply medication when misuse is suspected is a serious regulatory breach.
5. Governance failures can lead to restrictions on practice – Pharmacists must ensure they have proper record-keeping, stock control, and safeguarding procedures in place.

Conclusion

This case highlights the critical importance of responsible medicine supply and proactive engagement with regulatory processes. The three-month conditions of practice order serves as a final opportunity for the registrant to demonstrate full remediation before further action is considered.