Pharmacist Suspended for Six Months After Supplying Controlled Drugs on Invalid Prescriptions

The General Pharmaceutical Council (GPhC) Fitness to Practise Committee investigated a pharmacist after he was found to have supplied large quantities of controlled drugs using invalid and fraudulent prescriptions.

Between January 2018 and February 2019, he:

1. Dispensed Fentanyl, Tramadol, and other controlled drugs despite prescription irregularities.
2. Ignored multiple warning signs that the prescriptions were altered or fraudulent.
3. Failed to conduct basic verification checks with the issuing prescribers.
4. Put Patient A at risk of harm by facilitating the over-supply of addictive medications.

The GPhC was alerted following an investigation by the Counter Fraud Team at South Warwickshire NHS Trust and West Midlands Police.

Findings:

The Fitness to Practise Committee found that the pharmacist’s conduct amounted to serious professional misconduct, considering:

1. Repeated Dispensing of Controlled Drugs on Invalid Prescriptions:
   • The pharmacist supplied opioid medications (Fentanyl, Tramadol) based on prescriptions that lacked essential details.
   • Some prescriptions were expired, missing the drug name, or contained altered dosages without a counter-signature.
   • The committee noted:“It is a fundamental responsibility of a pharmacist to ensure prescriptions are legally valid before dispensing medication, particularly for controlled drugs.”
2. Failure to Identify or Act on Multiple ‘Red Flags’ Indicating Fraud:
   • The pharmacist ignored numerous warning signs that the prescriptions were fraudulent, including:
     • Handwritten alterations.
     • Prescriptions issued under multiple doctor names.
     • High and increasing doses of opioids.
   • Despite these warning signs, no verification calls were made to the issuing doctors.
3. Over-Trusting Relationship with Patient A:
   • The pharmacist allowed his personal trust in Patient A to override professional responsibility.
   • He admitted he considered Patient A a mentor and took his explanations at face value.
   • The committee remarked:“Pharmacists are the guardians of the nation’s medicine cabinets. In this case, the registrant failed in that duty.”
4. Admission of Fault and Late Realisation of Seriousness:
   • The pharmacist accepted full responsibility and demonstrated remorse.
   • However, his insight developed only after the investigation began, rather than at the time of dispensing.

GPhC Determination on Impairment:

The GPhC ruled that the pharmacist’s fitness to practise was impaired, citing:

• Failure to comply with legal requirements for controlled drug dispensing.
• Serious professional incompetence in failing to verify prescriptions.
• Damage to public confidence in pharmacy as a safe healthcare profession.

The committee stated:

“The pharmacist’s conduct facilitated the excessive and potentially harmful supply of opioids without proper oversight. The public must have confidence that pharmacists act as a safeguard against misuse and addiction.”

However, the committee acknowledged that:

• The pharmacist had fully admitted his wrongdoing.
• He had since completed professional training to prevent recurrence.
• There was no evidence that Patient A suffered harm as a direct result of the pharmacist’s actions.

Given these factors, the committee found that:

“While the risk of repetition is low, the seriousness of the breach requires regulatory action to uphold public trust.”

Sanction:

The committee imposed a six-month suspension, considering:

• Aggravating Factors:
  • Failure to detect and prevent fraudulent prescriptions over a prolonged period (one year).
  • Supply of high-risk opioid medications without proper checks.
  • Multiple prescribers and surgeries involved, increasing the likelihood of fraud.
• Mitigating Factors:
  • The pharmacist reported concerns about prescriptions to NHS England, demonstrating eventual awareness.
  • He showed genuine remorse and had undertaken remedial training.
  • He had no previous disciplinary history and was highly regarded in his community.

The committee ruled that:

“Suspension is necessary to maintain public confidence, but the registrant’s remediation means removal is not justified.”

A review hearing was not required, as the committee was satisfied that the pharmacist would not repeat his mistakes.

Key Learning Points for Pharmacy Professionals:

This case highlights critical lessons regarding controlled drug dispensing, professional judgment, and safeguarding against fraud.

1. Pharmacists Must Always Verify Controlled Drug Prescriptions:
   • If a prescription appears altered or incomplete, pharmacists must contact the prescriber before dispensing.
   • Even long-standing patients should not receive special treatment in professional decision-making.
2. Personal Trust Must Never Override Professional Responsibility:
   • The pharmacist allowed his personal relationship with Patient A to influence his clinical decisions.
   • Pharmacists must maintain objectivity, even with familiar patients.
3. A ‘Red Flag’ Should Always Trigger Investigation:
   • Multiple prescription amendments, large quantities of opioids, or frequent prescription changes should raise concerns.
   • If something seems wrong, pharmacists must take action.
4. Regulatory Action Is Necessary to Maintain Public Confidence:
   • The suspension reflects the seriousness of the breach, even though no harm was proven.
   • Pharmacists must ensure they comply with legal requirements at all times.

Conclusion:

This case serves as a strong reminder that pharmacists must be vigilant in checking the validity of prescriptions, especially for controlled drugs.

While the pharmacist avoided removal from the register, his six-month suspension reinforces the importance of professional diligence and safeguarding public trust.

Pharmacists must always prioritise patient safety and professional responsibility over personal relationships.