Pharmacist Removed from Register for Unsafe Storage and Intended Reuse of Out-of-Date Medicines

Date of Decision: December 16, 2019

Registrant's Role: Pharmacist

Allegations:

Asked an individual to store pharmaceutical waste (DOOP bins) in his garage.
Requested that the same individual compile inventories of out-of-date medicines.
Intended to reuse medications that were expired.
Failed to ensure safe and effective storage of medication by instructing untrained individuals to handle pharmaceutical waste.

Outcome: Removal from the GPhC register

GPhC Standards Breached:

Standard 1.1 – Make sure the services you provide are safe and of an acceptable quality
Standard 1.2 – Take action to protect the well-being of patients and the public
Standard 1.6 – Do your best to provide medicines and other professional services safely and, when patients need them
Standard 2.1 – Consider and act in the best interests of individual patients and the public
Standard 2.2 – Make sure that your professional judgement is not affected by personal or organisational interests
Standard 6.2 – Not abuse your professional position or exploit the vulnerability or lack of knowledge of others
Standard 6.5 – Comply with legal and professional requirements and accepted guidance on professional practice
Standard 6.5 (repeated) – Meet accepted standards of personal and professional conduct
Standard 7.4 – Take responsibility for all work you do or are responsible for. Make sure that you delegate tasks only to people who are trained to do them, or who are being trained

Case Summary

Allegations

The case centred on the registrant, a superintendent pharmacist, who was found to have seriously breached professional and regulatory standards in her handling of pharmaceutical waste and expired medications. Over a period spanning July 2016 to March 2017, she was accused of:

Instructing an individual, with whom she was in a personal relationship, to store pharmaceutical waste (DOOP bins) at his home.
Requesting that the same individual inventory expired medications.
Intending to reuse out-of-date medications, including controlled drugs such as Verapamil and Ferrous Gluconate.
Failing to ensure the safe and effective storage of the waste, with bins left outside regulatory oversight for extended periods.

These actions, if proven, carried significant implications for public health, regulatory trust, and the integrity of pharmacy practice.

Findings

The Fitness to Practise Committee found all four allegations proven. Evidence from the complainant, an individual personally involved with the registrant and not a trained pharmacy professional, was extensively corroborated by text messages, photographs, and an independent digital forensics report.

The messages revealed that the registrant had requested specific medications from the DOOP bins, with text exchanges such as:

“Morning! Can I have the verapamil from no 1? X” – sent by the registrant on 5 August 2016.

This undermined her defence that she was merely trying to confirm the bins’ location. Her explanation for not reporting the situation to the authorities, including the police or pharmacy inspectorate, was deemed implausible.

Witness credibility played a crucial role. The complainant was considered consistent and supported by data, whereas the registrant was found to have changed her account significantly between her first and second witness statements. In the first, she denied the duration of the relationship and denied awareness or instruction of the bin removals. In the second, she acknowledged the relationship lasted until March 2017 and described feeling coerced, stating in her own words:

“I continued with the relationship in an ill-fated attempt to try and recover the DOOP bins from him. To put it plainly, it was ‘hopeful sex’ in that I would hope he would return the DOOP bins to me if I were to keep sleeping with him. I actually thought, and I still do think, that I prostituted myself.”

Despite this emotional narrative, the committee found her version inconsistent and lacking credibility, especially in light of her professional obligations.

GPhC Determination on Impairment

The committee concluded that the registrant’s conduct constituted serious professional misconduct. This judgment was based on the prolonged nature of the misconduct, the registrant’s failure to rectify the situation, and the potential risk posed to public health. Factors considered included:

The storage of DOOP bins containing expired and potentially misused medications outside the pharmacy.
The potential risk to children and untrained individuals with access to these bins.
A demonstrated intent to reuse medications, a practice grossly incompatible with patient safety.

Her failure to seek help from professional bodies, or even to report the issue to law enforcement, illustrated a lack of judgement and insight. Moreover, the registrant’s minimal reflection on the implications of her actions on public trust and safety indicated an ongoing risk to public protection.

Sanction

The committee ordered the removal of the registrant from the GPhC register. They found that lesser sanctions such as a warning, conditions, or suspension would not sufficiently protect public safety or uphold confidence in the profession. The decision acknowledged:

The registrant’s lack of significant insight or remediation.
The deliberate and sustained nature of the misconduct.
The presence of aggravating factors such as misuse of professional position, lack of transparency, and the involvement of untrained individuals.

While recognising the registrant’s personal hardships and professional disruption, the panel prioritised public protection, concluding:

“The risks the Registrant had created, and for which she was solely responsible, had been very substantial indeed… Her behaviour was incompatible with being a registered professional.”

Key Learning Points for Pharmacy Professionals

DOOP Bin Compliance: Pharmaceutical waste must be managed strictly according to regulatory guidelines. Removal or storage outside of the pharmacy undermines public safety and regulatory trust.
Boundaries and Professional Conduct: Personal relationships must not influence professional decisions. Delegating responsibilities to untrained individuals—even if personally trusted—is unacceptable and breaches multiple GPhC standards.
Insight and Remediation: Professionals under investigation must demonstrate genuine insight into their misconduct and take remedial actions. Vague apologies and personal hardship narratives are insufficient without clear evidence of learning and change.
Reporting and Transparency: Failure to report improper practices, especially those involving public risk, is a serious omission. Seeking advice from peers, regulatory bodies, or the police is a professional duty.
Recordkeeping and Communication: Digital communication, such as texts and emails, may be used as evidence. Professionals should be mindful that informal messages can carry significant weight in regulatory proceedings.

This case underscores the importance of adhering to professional standards, safeguarding patient health, and maintaining public trust. It serves as a cautionary example of how deviations—whether driven by personal circumstances or poor judgement—can lead to career-ending consequences.

Original Case Document

The full determination transcript is available to logged in users.