Pharmacist Suspended for Unlawful Medicine Supply, Drinking on Duty, and Failing Vulnerable Patients

Date of Decision: April 17, 2025

Registrant's Role: Pharmacist

Allegations:

Supplied diazepam and codeine-containing medicines to family members without prescriptions.
Self-medicated using codeine linctus taken from the pharmacy without authorisation or documentation.
Consumed alcohol while on duty in the pharmacy, impairing his judgement.
Failed to supply diazepam to a care home resident, later admitting he took the medication home.
Told a patient with dementia to call back later because “she wouldn’t remember” anyway.

Outcome: Suspension from the register for 3 months

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 5 – Use professional judgement
Standard 6 – Behave in a professional manner
Standard 9 – Demonstrate leadership

Case Summary

A number of allegations were made against the registrant, who was the owner, Director, and Superintendent Pharmacist, at the Pharmacy involved.

Unlawful Supply and Misuse of Medicines

The registrant admitted to:

Removing prescription-only and controlled medicines from the pharmacy to give to family members without prescriptions.
Personally using codeine linctus, taken from pharmacy stock without record or authorisation.
Failing to make any record of the supply or notify the superintendent pharmacist.

The GPhC noted this conduct breached fundamental legal and ethical duties.

Failure to Protect a Vulnerable Care Home Patient

A GP surgery contacted the pharmacy after a prescription for diazepam for a care home resident was reported missing. The registrant:

Initially denied any knowledge of the prescription.
Later admitted to taking the medicine home instead of supplying it.
Claimed the intention was to give it to a relative if needed.

“The prescription was for a care home resident. That person was by definition vulnerable.”
“Diverting medicine from such a patient seriously undermines public trust.”

Drinking While on Duty and Failing a Dementia Patient

The registrant admitted to drinking alcohol while working as the Responsible Pharmacist.

During one such shift, he took a call from a patient with dementia, but failed to deal with her request. He said:

“I told her to ring back in an hour. I knew she had dementia. I didn’t think she would remember.”

The Committee viewed this as a serious failure of care and judgement.

Insight and Engagement

The registrant:

Admitted all charges and provided some reflective writing.
Acknowledged the stress and burnout that contributed to his misconduct.
Did not attempt to minimise or deny the seriousness of his actions.
Submitted some CPD evidence and expressed remorse, although the Committee found the insight partial and undeveloped.

GPhC Determination on Impairment

The panel found the registrant’s fitness to practise to be currently impaired, due to:

The seriousness and repetition of the misconduct.
The impact on vulnerable patients and the reputational damage to the profession.
A risk of repetition, given the lack of fully developed insight.

“The misconduct involved a serious departure from the standards expected of a pharmacy professional.”

Sanction

The GPhC considered erasure but found that a 3-month suspension would:

Mark the seriousness of the misconduct
Allow time for the registrant to reflect and remediate
Be sufficient given his admissions, partial insight, and clean history

“The Committee considered that suspension for a period of three months would be sufficient and proportionate.”

An interim suspension order was imposed to take effect immediately.

Key Learning Points for Pharmacy Professionals

Supplying medicines without a prescription is unlawful, regardless of circumstances or intentions.
Drinking while on duty compromises patient safety and professional integrity.
Patients with dementia and care home residents require the highest level of care and accountability.
Full, reflective insight and proactive remediation are essential to avoid harsher outcomes.
Engaging meaningfully with the regulator is crucial for demonstrating professionalism and potential for recovery.

Conclusion

This case demonstrates the serious consequences of unlawful medicine supply, misuse, and impaired professional judgement. While the GPhC found erasure unnecessary, the 3-month suspension reflects the gravity of the registrant’s conduct, particularly toward vulnerable patients. Pharmacy professionals are reminded that stress and burnout must never compromise public safety or ethical standards, and that remediation must be genuine, thorough, and timely.

Original Case Document

The full determination transcript is available to logged in users.