Pharmacist Suspended for Six Months Following Methadone Dispensing Errors and Lack of Integrity

The GPhC Fitness to Practise Committee reviewed the case of a pharmacist, referred to here as “the registrant,” who faced allegations of serious dispensing errors, failure to maintain controlled drug records, and dishonesty in handling a dispensing error report.

This case highlights significant breaches of controlled drug regulations, professional integrity, and open communication with healthcare professionals.

---

Allegations and Proven Findings

1. Dispensing Methadone Without a Valid Prescription
   • The registrant supplied methadone to Patient A despite there being no legally valid prescription in place.
2. Failure to Maintain Controlled Drug Records
   • The registrant failed to properly update the Controlled Drug Register, resulting in discrepancies in the pharmacy’s methadone records.
3. Dishonesty in Communicating with a GP
   • During a discussion with Patient A’s GP, the registrant initially denied making an error in dispensing methadone.
   • The registrant later requested that the GP not report the dispensing error, which the committee found to be a serious breach of integrity.
4. Dispensing Contrary to Directions on Prescriptions
   • The registrant failed to follow the instructions provided on methadone prescriptions, resulting in potential patient safety risks.

---

Fitness to Practise Findings

The Committee determined that the registrant’s actions:

• Compromised Patient Safety
  • Methadone is a controlled drug that requires strict prescribing and dispensing safeguards.
  • Failure to follow correct procedures increases the risk of medication misuse, overdose, or harm to patients.
• Demonstrated a Lack of Integrity
  • The registrant’s request to conceal a dispensing error from a GP was a serious breach of professional trust.
• Undermined Public Confidence in the Profession
  • Dishonest conduct, particularly in the context of controlled drug handling, damages the reputation of pharmacy professionals and the public’s trust in pharmacy services.
• Highlighted Poor Record-Keeping Practices
  • Accurate Controlled Drug Register (CDR) entries are legal requirements under UK pharmacy regulations.
  • Failure to maintain accurate records indicates poor governance and a lack of professional accountability.

---

Outcome and Sanctions

The GPhC imposed a six-month suspension to reflect the serious nature of the breaches. The Committee noted:

• The registrant had an otherwise unblemished 37-year career, which was considered in mitigation.
• Steps were taken towards remediation, including resignation as Superintendent Pharmacist.
• However, public confidence in the profession required a suspension, particularly given the registrant’s initial dishonesty and failure to take full responsibility.

The suspension will be reviewed before expiry, allowing the registrant an opportunity to demonstrate full remediation before returning to practice.

---

Key Learning Points for Pharmacy Professionals

1. Controlled Drug Regulations Must Be Followed Strictly
   • Methadone and other Schedule 2 controlled drugs require rigorous documentation and compliance with legal requirements.
2. Integrity and Transparency Are Essential
   • Pharmacists must be open and honest when errors occur.
   • Attempting to conceal mistakes or mislead other healthcare professionals can result in serious regulatory action.
3. Controlled Drug Register Records Must Be Accurate
   • Every supply of Schedule 2 medications must be recorded accurately in the Controlled Drug Register (CDR).
   • Inaccurate record-keeping can lead to serious regulatory consequences.
4. Requesting Colleagues to Cover Up Errors Is Unacceptable
   • When errors happen, pharmacists should report them promptly, engage in root cause analysis, and take corrective action rather than trying to suppress incidents.
5. Regulatory Sanctions Can Reflect Both Breaches and Mitigation
   • Even with a previously unblemished record, dishonesty and unsafe practices can still result in suspension or removal.
   • Remediation efforts must be genuine, proactive, and fully evidenced before reinstatement is considered.