Pharmacist Suspended for Nine Months Following Repeated Non-Compliance with Conditions and Ongoing Risk to Patient Safety

Date of Decision: August 6, 2020

Registrant's Role: Pharmacist

Allegations:

A series of Controlled Drug (CD) recording and dispensing errors over a three-month period, including supply under expired prescriptions, incorrect CD balances, and failure to record key CD data.
Aggressive behaviour towards a pharmacy manager.
Working without a supervisor or completing CPD as directed by the GPhC in prior fitness to practise decisions.
Failure to comply with multiple sets of previously imposed conditions, including non-submission of training, supervision, and development records.

Outcome: Nine-month suspension

GPhC Standards Breached:

Standard 5 – Use professional judgment
Standard 6 – Behave in a professional manner
Standard 8 – Speak up when things go wrong
Standard 9 – Demonstrate leadership

Case Summary

The pharmacist originally faced numerous allegations dating back several years, including:

Incorrect supply of CDs (MST, Methadone, Concerta XL, Zomorph, Buprenorphine) and failure to make or correct entries in the CD register.
Supplying methadone under expired prescriptions.
Failure to safely store CDs, leaving stock unsecured.
Dispensing errors, such as mislabelling strengths and incorrect recording in registers.
Aggressive conduct towards a manager during a discussion about compliance.

The registrant admitted to most allegations and was previously subject to:

A 9-month order of conditions, then
A 6-month suspension, then
Another 9-month order of conditions.

Despite repeated opportunities, the registrant continued to show:

Non-compliance with supervision, training, and record-keeping conditions.
Lack of insight and failure to provide required remediation materials.

Findings from the Current Review Hearing

The registrant acknowledged that he:

Had not complied with the order of conditions.
Worked without a supervisor, assuming the agency would inform employers.
Failed to complete or arrange required CD training, citing cost and COVID-19 as reasons.
Did not report a recent dispensing error to the GPhC, violating the conditions.
Failed to provide a reflective report, testimonials, or CPD, as previously requested.

The Committee concluded:

“The Registrant had complied with none of the Conditions set out in the present Order.”

They found that despite repeated chances, the registrant:

Had not demonstrated insight into his original misconduct.
Failed to understand the importance of proactive engagement with conditions.
Displayed “a woeful lack of insight into his professional obligations.”

GPhC Determination on Impairment

The Committee concluded the registrant’s fitness to practise remains impaired, citing:

Ongoing risk to patient safety.
Lack of engagement and disregard for regulatory processes.
Failure to demonstrate that misconduct is unlikely to be repeated.

“The Registrant’s plea that he did take the Conditions seriously could not be squared with his apparent disregard of them.”

Sanction

The Committee imposed a nine-month suspension, reasoning:

Conditions were no longer workable or proportionate, due to repeated non-compliance.
Suspension was necessary to protect the public, uphold professional standards, and maintain public confidence.
Interim suspension was also granted with immediate effect under Article 60 of the Pharmacy Order.

They stated:

“This suspension gives the Registrant a final opportunity to reflect, provide evidence, and demonstrate that he can safely return to practice.”

A further review will occur before the end of the suspension.

Key Learning Points for Pharmacy Professionals

Compliance with GPhC conditions is not optional—it is essential for public protection and professional accountability.
Engaging with remediation proactively is crucial. Failing to provide requested documents, reports, or reflections undermines your case.
Insight must be demonstrated, not just claimed—words must be backed by action and evidence.
Controlled Drug mismanagement carries serious implications, including suspension or removal from the register.
Blaming external factors (e.g. COVID-19 or agencies) is not a defence when your own obligations remain unfulfilled.

Conclusion

This case illustrates that repeated non-compliance with GPhC-imposed conditions, especially following serious Controlled Drug errors, leads to escalating sanctions. The pharmacist was given several opportunities to remediate but failed to act. The nine-month suspension sends a clear message: pharmacy professionals must take their obligations seriously and show sustained, evidence-based progress toward regaining public trust.

Original Case Document

The full determination transcript is available to logged in users.