Pharmacist Suspended for 12 Months Over Governance Failures at Cannabis-Based Medicines Pharmacy

The General Pharmaceutical Council (GPhC) investigated two registrants following serious governance failures at Cannabliss Pharmacy, which specialized in dispensing Cannabis-Based Medicinal Products (CBMPs).

Between February 2021 and May 2022, the pharmacy:

• Operated without proper risk assessments or safeguarding policies.
• Dispensed high-risk medicines to vulnerable patients without adequate checks.
• Failed to maintain accurate Responsible Pharmacist (RP) records, with multiple instances of the pharmacy operating without an RP signed in.
• Allowed an unqualified company director to manage pharmacy operations and make Controlled Drug register entries.

A GPhC inspection in May 2022 found severe compliance breaches, leading to regulatory action.

Findings

The GPhC panel found that:

• 96 out of 212 Controlled Drug register entries were recorded late, a major compliance red flag.
• 39 supply records were made when no RP was signed in, raising concerns about accountability.
• Five patients received prescriptions from multiple prescribing services, with no evidence of intervention or risk assessment.
• CBMPs and Schedule 2 Controlled Drugs were not stored securely in a CD cabinet.
• Several pre-signed dispensing labels were found, a practice that violates professional standards.

A direct quote from the ruling underscored the severity of the governance failures:

“The registrant demonstrated a complete lack of oversight in managing a high-risk pharmacy, jeopardizing patient safety and public confidence in the profession.”

GPhC Determination on Impairment

The committee concluded that both registrants’ fitness to practise was impaired due to:

• Public protection concerns, as the pharmacy’s operational failures put patients at risk.
• Failure to take accountability, particularly by the superintendent pharmacist.
• Serious breaches of professional standards, particularly in handling Controlled Drugs.

While Registrant 2 demonstrated some remorse and remediation, Registrant 1 showed limited insight and engagement with the regulatory process.

Sanction

Registrant 1 (Superintendent Pharmacist) – 12-Month Suspension

• The registrant failed to engage with the GPhC and dismissed the proceedings as unnecessary.
• The pharmacy’s failures posed serious risks to public health.
• The attitude towards governance was dismissive, raising concerns about future risks.
• The suspension allows the registrant a final opportunity to demonstrate remediation before potential removal.

Registrant 2 (Responsible Pharmacist) – Formal Warning

• Demonstrated remorse and reflection, including professional development.
• The risk of repetition was low, and there were no public safety concerns.
• A warning serves as a public declaration of unacceptable professional conduct.

Additionally, an interim suspension was imposed immediately on Registrant 1, preventing them from practising until the full suspension takes effect or an appeal is resolved.

Key Learning Points for Pharmacy Professionals

1. Pharmacies dispensing high-risk medicines require strict oversight – Poor governance of Cannabis-Based Medicinal Products (CBMPs) and Controlled Drugs can lead to severe regulatory action.
2. The Responsible Pharmacist must be present and recorded – Operating without a signed-in RP is a serious breach of professional standards.
3. Controlled Drug records must be meticulously maintained – Late or missing entries raise regulatory concerns and suggest unsafe practices.
4. Regulatory engagement is essential – Failing to cooperate with the GPhC worsens outcomes and may lead to harsher sanctions.
5. Storage and security of Controlled Drugs are non-negotiable – The failure to store Schedule 2 CDs correctly indicated systemic governance failures.

Conclusion

This case underscores the importance of governance and compliance when managing high-risk medicines. The 12-month suspension for Registrant 1 serves as a clear warning that failing to implement basic pharmacy safeguards will lead to serious regulatory consequences. Meanwhile, Registrant 2’s warning highlights that even secondary failings in governance require accountability and remediation.