Pharmacist Placed Under Conditions Following Repeated Governance Failures in Codeine Linctus Supply
Date of Decision: March 7, 2025
Registrant's Role: Pharmacist
Allegations:
- Failure to manage the risks associated with the sale of codeine linctus and prevent potential misuse or addiction.
- Supplying large volumes of codeine linctus without adequate clinical justification.
- Continuing to supply codeine linctus to two individuals despite suspicions of misuse or dependence.
- Failing to maintain adequate stock control, purchase records, and governance measures.
- Failure to engage with previous regulatory conditions, leading to an earlier suspension.
Outcome: Conditions of practice imposed for three months
GPhC Standards Breached:
- Standard 1 – Provide person-centred care
- Standard 5 – Use professional judgment
- Standard 9 – Demonstrate leadership
Case Summary
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:
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