Pharmacist Sanctioned for Inappropriate and Excessive Codeine and Phenergan Supplies

Date of Decision: August 27, 2025

Registrant's Role: Pharmacist

Allegations:

Failure to implement up-to-date SOPs on high-risk opioid medicines.
Inappropriate ordering of large quantities of Codeine Linctus and Phenergan Elixir.
Lack of systems to monitor and audit ordering, sale, and supply of high-risk medicines.
Specific large orders of Codeine Phosphate and Co-codamol without proper oversight.

Outcome: Conditions imposed for 6 months

GPhC Standards Breached:

Standard 1 – Provide person-centred care.
Standard 5 – Use professional judgement.
Standard 9 – Demonstrate leadership.

Case Summary

Allegations

This case centres on the registrant’s conduct as a Superintendent Pharmacist and Responsible Pharmacist at two community pharmacies: Your Prescriptions Ltd, an online pharmacy, and Al-Shafa Pharmacy. The central concern was the inappropriate procurement and poor governance over the handling of high-risk medicines, particularly Codeine Linctus and Phenergan Elixir, both known for their abuse potential.

The registrant admitted to the following:

Failing to ensure effective and up-to-date Standard Operating Procedures (SOPs) for the handling of high-risk opioid medications.
Authorising or allowing substantial orders of Codeine Linctus (up to 150 bottles at a time) and Phenergan Elixir, without justification or audit trails.
Absence of systems to monitor and audit the ordering and supply of these medicines, which are liable to abuse, misuse, or being used in combination as recreational concoctions (“purple drank”).
Specific orders included 300 tablets of Codeine Phosphate 60mg and 500 tablets of Co-codamol 30/500mg, flagged by the supplier’s algorithm due to the suspicious volume.

The GPhC inspectors found incomplete RP logs, absent or unsigned SOPs, lack of proper invoice storage, and cluttered pharmacy environments. The investigation revealed that only small quantities of Codeine were dispensed via NHS prescriptions, inconsistent with the large volumes ordered—indicating poor oversight and possibly untracked private sales or diversion.

Findings

The panel found that the registrant had significantly failed in his governance responsibilities. He had permitted inadequately trained staff to manage the ordering and supply of high-risk medicines without sufficient control measures. His dual role as SI and RP meant he held ultimate responsibility, which he had abdicated.

The registrant’s pharmacies failed to comply with regulatory expectations. For instance, invoices from Ethigen, DE Group, and others showed repeated large orders for Codeine and Phenergan, with little or no documentation on their legitimate use. Audits were non-existent, and the SOPs provided were outdated or lacked version control.

“The Registrant had abrogated some of his responsibilities as a SI…He had allowed staff, who were not properly trained or competent, to make decisions about ordering large volumes of high-risk medicines…in the absence of clear updated SOPs and adequate systems.”

While no direct patient harm was proven, the potential for harm was considered high, especially given the registrant’s failure to consider the known local context of substance misuse.

GPhC Determination on Impairment

The registrant’s fitness to practise was found to be impaired under Rule 5(2)(a), due to a potential ongoing risk to patients and the public. The Committee also initially found impairment under Rules 5(2)(b) and 5(2)(c), relating to reputational harm and breach of fundamental professional principles.

Despite showing remorse, completing some CPD training, and stepping down from managerial roles, the registrant failed to provide key evidence at review, including updated SOPs, audit systems, or reflections addressing the patient safety implications of his failings.

The Committee found his insight still developing and noted gaps in remediation. While the risk of repetition was deemed low if the registrant avoided managerial roles, concerns persisted around future governance capabilities.

Sanction

At the August 2025 review, the original two-month suspension was replaced with a six-month Conditions of Practice Order. The Committee judged that a full suspension was no longer proportionate, but restrictions were necessary to safeguard the public.

Key conditions included:

Prohibition from acting as a Superintendent Pharmacist, Sole Practitioner, or Responsible Pharmacist.
Requirement to work under close supervision, with GPhC-approved supervisors.
Mandated training on Responsible Pharmacist duties and governance.
Prohibition from working in family-owned pharmacies to ensure independent oversight.

The Committee highlighted that conditions were appropriate as there were no concerns about the registrant’s clinical competency, and he remained employable under proper safeguards.

“It was not proportionate or in the public interest, or the Registrant’s interest, to further deprive the public of an otherwise competent pharmacist.”

Key Learning Points for Pharmacy Professionals

Governance Responsibilities Are Non-Negotiable: Pharmacists in managerial roles must ensure robust systems are in place, particularly for high-risk medicines. SOPs must be current, signed, and auditable.
High-Risk Medicines Demand Vigilance: The volume of Codeine Linctus and Phenergan Elixir ordered was inconsistent with the dispensing activity, signalling a red flag for diversion or misuse. Pharmacists must monitor ordering patterns, maintain accurate logs, and justify quantities.
Insight and Documentation Matter in Regulatory Reviews: Despite verbal assurances, the registrant’s lack of supporting evidence—such as updated SOPs, reflections, and testimonials—undermined his case. Professionals facing GPhC scrutiny must proactively compile remediation portfolios.
Separation from Ownership or Management Can Aid Rehabilitation: The registrant’s commitment to avoiding SI and RP roles was a mitigating factor. When professional failings stem from governance lapses, returning to practice under supervision can support safe reintegration.
Environmental and Community Context is Crucial: Operating in areas known for substance misuse necessitates extra caution. Failing to account for this elevates risk and regulatory concern.

This case serves as a stark reminder of the risks associated with inadequate pharmacy governance, particularly concerning high-risk and abuse-prone medications. It also highlights the importance of proactive remediation and comprehensive reflection when seeking to return to practice following regulatory sanctions.

Original Case Document

The full determination transcript is available to logged in users.