Pharmacist Suspended for Controlled Drug Governance Failures and Inadequate Oversight as Superintendent

Date of Decision: February 24, 2026

Registrant's Role: Pharmacist

Allegations:

Failed to put measures in place to maintain the supervision and safe running of the pharmacy whilst off sick from 31 May 2022 until a date unknown in July 2022.
Failed to ensure the Responsible Pharmacist (RP) log was adequately maintained: The RP log showed the registrant signed in as RP between 1 June 2022 and 20 July 2022 whilst off sick; The RP log did not show the correct RP on duty during that period.
Failed to put in place sufficient pharmacy records in line with guidance: No near miss log; No Information Commissioner’s Office (ICO) registration until 21 July 2022.
Failed to comply with safe custody requirements for Controlled Drugs (CDs) by storing the following in a drawer in August 2022: Three ampoules of morphine sulphate; Five Butec patches; Approximately 29 boxes of buprenorphine tablets.
Failed to store CDs in a locked cabinet by leaving: A glass measure containing Physeptone solution; A 500ml bottle of Physeptone solution on a bench.
Failed to keep accurate balance checks of Physeptone SF solution.
Failed to keep CD register entries accurate and up to date, including discrepancies involving morphine sulphate and Zomorph.
Failed to ensure sufficient procedures or controls to account for large quantities of codeine linctus (Galenphol and Galcodine) purchased and supplied.
Between 8 August 2022 and 31 August 2023: Failed to ensure CD registers were accurate and up to date (Zomorph and Oxycodone proved; Physeptone not proved); Failed to ensure patient-returned CDs were accurately recorded and disposed of.

Outcome: Suspension for 3 months with review (interim suspension imposed).

GPhC Standards Breached:

Standard 6 – Pharmacy professionals must behave in a professional manner.
Standard 8 – Pharmacy professionals must speak up when they have concerns or when things go wrong.
Standard 9 – Pharmacy professionals must demonstrate leadership.

Case Summary

Allegations

This case concerned a pharmacist who was the Superintendent Pharmacist (SI), owner, and regular Responsible Pharmacist (RP) of a community pharmacy. The concerns arose following an NHS England inspection in July 2022 and subsequent GPhC inspections.

At the time of the first inspection, the registrant was off sick following a heart attack. However, inspectors identified significant governance failings. The RP log incorrectly showed the registrant signed in daily during a period when he was absent. There was no accessible locum pack, no near miss log, and no ICO registration in place.

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