Pharmacist Suspended After Failing to Comply with Conditions Over Controlled Drugs and Dispensing Errors

Date of Decision: April 15, 2019

Registrant's Role: Pharmacist

Allegations:

Numerous and serious errors in the handling of Controlled Drugs (CDs)
Dispensing errors over a period of several months (August 2016 – February 2017)
Inadequate record-keeping
Failure to comply with conditions imposed by the GPhC following initial hearing
Failure to engage with regulatory process post-conditions order

Outcome: 6-month suspension order with review

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 2 – Work in partnership with people
Standard 3 – Communicate effectively
Standard 4 – Maintain, develop and use professional knowledge and skills
Standard 6 – Behave professionally
Standard 7 – Respect and maintain a person’s confidentiality and privacy
Standard 9 – Demonstrate leadership

Case Summary

Allegations

The registrant, a pharmacist, faced a review hearing following serious professional failings identified during a previous principal hearing held in 2018. The original allegations related to a range of misconduct spanning approximately six months, from August 2016 to February 2017. These included multiple dispensing errors, breaches of Controlled Drugs (CDs) legislation, and poor record-keeping.

In the original hearing, the registrant admitted to nearly all the allegations, describing his actions as “deplorable”. Despite this, a set of conditions was imposed rather than immediate suspension or erasure, largely due to mitigating factors such as the registrant’s previously unblemished record, his partial insight, expressed remorse, and engagement with the proceedings.

The conditions included requirements for regular reporting to the General Pharmaceutical Council (GPhC), appointment of a workplace supervisor, provision of personal development plans, and mandatory training concerning controlled drugs. Specific conditions (e.g. C18, C19, C21, C26, and C29) were designed to support remediation while ensuring public safety.

However, the review hearing revealed a lack of compliance with these conditions, raising significant concerns about patient safety and professional accountability.

Findings

The panel found the registrant’s fitness to practise to still be impaired. This decision was based on overwhelming evidence of non-compliance with conditions previously imposed, including:

No evidence of a professional development report
No engagement with a workplace supervisor
No documentation showing continuing development of insight
No updates regarding current employment or practice status

Furthermore, the GPhC’s monitoring officer reported multiple breaches of key conditions. Alarmingly, there was no indication that the registrant was not currently practising, which meant he could be doing so in breach of his conditions—a direct risk to public safety.

The registrant had ceased engagement with the GPhC since August 2018, with only minimal communication via email to request an adjournment of the review hearing on the grounds of ill health. This request was unsupported by any medical evidence or documentation, which severely undermined its credibility.

“There is no evidence of the improvements that were suggested to him as being of benefit to this Committee. There is therefore no evidence of remediation to satisfy the Committee that the public is not currently at risk.”

GPhC Determination on Impairment

The panel determined that the registrant’s fitness to practise remained impaired. The reasons were twofold:

Non-Compliance with Conditions: There was substantive evidence that the registrant had not adhered to the conditions intended to support remediation. In the absence of evidence demonstrating insight, training, or supervised practice, the panel had no assurance that he was safe to continue practising.
Public Protection and Confidence: Given the registrant’s lack of engagement and failure to demonstrate remediation, the committee highlighted the potential risk to patients and the public. The registrant’s disregard for the regulatory process also risked undermining public confidence in the pharmacy profession.

The panel referred to Yeong and Abrahaem case law, emphasizing that remediation and demonstrated insight are essential for lifting an impairment finding. The registrant had shown neither.

Sanction

Having determined ongoing impairment, the panel then considered the appropriate sanction. While the original panel had opted for conditions due to the registrant’s initial cooperation and partial insight, the current committee noted that circumstances had significantly changed.

Given the breaches of those conditions and continued non-engagement, the panel concluded that a suspension was the only proportionate and protective action.

Although the Council argued for the maximum 12-month suspension, the panel decided on a 6-month suspension. This decision was intended to give the registrant a final opportunity to re-engage with the GPhC, address his health issues, develop insight, and present evidence of remediation before a further review.

The decision emphasized that a future reviewing committee would need concrete evidence of:

Remedial training
Reflective insight
Compliance with regulatory expectations
Health-related treatment or support if relevant

Should the registrant fail to provide such evidence, more severe sanctions, including erasure, may be considered.

Key Learning Points for Pharmacy Professionals

Engagement with the Regulator is Crucial: Failing to respond or comply with the GPhC, especially after previous findings, can be seen as a serious aggravating factor. It reflects poorly on a pharmacist’s professionalism and judgment.
Conditions are Not Optional: If conditions are imposed as part of a regulatory outcome, pharmacists must treat them as binding requirements. Selective compliance or non-compliance is a direct threat to patient safety and will be taken seriously.
Controlled Drug Handling Requires Vigilance: Errors involving CDs attract heightened scrutiny and regulatory consequences. Pharmacists must ensure they are thoroughly familiar with all legal, procedural, and clinical requirements.
Insight and Remediation Matter: Panels give significant weight to a registrant’s ability to reflect on their errors, show remorse, and take concrete steps toward remediation. This includes CPD, supervision, and formal reflective statements.
Health and Fitness to Practise Are Linked: If a registrant cites health issues as a barrier to compliance, this must be supported with clear, timely medical evidence. Unsupported claims can undermine credibility and fail to justify adjournments or leniency.
Professional Isolation Can Be Risky: Practising without proper supervision or peer support, especially after failings have been identified, increases risk and regulatory scrutiny.

This case serves as a stark reminder that remediation is not merely a checkbox—it’s a rigorous process requiring consistent engagement, honesty, and proactive professional development. Pharmacy professionals must take regulatory conditions seriously and use them as an opportunity to rebuild trust, competence, and safe practice.

Original Case Document

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