Pharmacist Suspended Over Mismanagement of High-Risk Medicines During COVID and Brexit Disruption

Date of Decision: June 16, 2025

Registrant's Role: Pharmacist

Allegations:

• Failure to implement up-to-date SOPs for the sale and supply of high-risk opioid medicines at two pharmacies.
• Ordering or allowing the ordering of excessive quantities of Codeine Linctus and Phenergan Elixir, which are liable to misuse and abuse.
• Failure to have adequate monitoring or audit systems for the ordering and sale of these high-risk medicines.
• Placing unusually large orders for Codeine Phosphate and Co-codamol without adequate justification.

Outcome: 2 month suspension

GPhC Standards Breached:

• Standard 5 – Use professional judgement
• Standard 6 – Behave professionally
• Standard 9 – Demonstrate leadership

Case Summary

Allegations
The case concerned a pharmacist who was the Superintendent Pharmacist at two Birmingham-based pharmacies: Your Prescriptions Ltd, an online pharmacy, and Al-Shafa Pharmacy, a high-volume community pharmacy. During the period from 2019 to 2020, the registrant was responsible for a series of failings involving the procurement and supply of high-risk medicines including Codeine Linctus, Phenergan Elixir, Codeine Phosphate, and Co-codamol.

The core allegations centred around ordering and permitting the ordering of large quantities of Codeine Linctus and Phenergan Elixir, both of which are susceptible to misuse—particularly when mixed to create a recreational concoction known as “Purple Drank” or “Lean.” The registrant failed to maintain updated SOPs or adequate audit systems to monitor these medicines’ movement. Notably, orders such as 150 bottles of Codeine Linctus in a single month and 220 bottles of Phenergan Elixir across a short span raised alarms. There were no corresponding patient needs documented to justify these stock levels, and only small quantities were found in use or on the premises during inspections.

Findings
The registrant admitted all allegations. GPhC inspections revealed systemic disorganization. At Your Prescriptions Pharmacy, SOPs lacked version control, many documents were unsigned, and the RP log was incomplete. The pharmacy had little NHS prescription volume, yet was ordering bulk quantities of controlled and high-risk drugs.

At Al-Shafa Pharmacy, similar issues persisted. Invoices showed repeated bulk orders, yet staff were unclear about their use or whereabouts. The pharmacy lacked robust stock control, and the consultation room was improperly used as storage space. Witnesses described daily over-the-counter sales of Codeine Linctus without proper oversight or questioning of customer need. Dispensers and pharmacists confirmed there was no system in place to record refusals or identify potential misuse patterns.

Ethigen Ltd, a wholesaler, had flagged the pharmacy’s orders as abnormal. Their algorithm triggered “Volume Supply Assessment” (VSA) forms that were not returned. A comment made by the registrant—”you ask too many questions”—regarding these forms was viewed as dismissive and indicative of poor regulatory cooperation.

GPhC Determination on Impairment
The panel determined the registrant’s fitness to practise was impaired due to misconduct. It concluded the pharmacist had failed to demonstrate leadership, professional judgment, and adequate systems to manage high-risk medications, breaching Standards 5, 6, and 9 of the GPhC professional standards. While no actual patient harm was identified, the potential for significant harm existed, especially due to the medicines involved and their known misuse risks.

“The registrant did not seek to minimise his failings and expressed much remorse for them. He had reflected deeply on his conduct, learnt a lot of difficult lessons and recognised the seriousness of what had gone wrong.”

The panel noted mitigating factors, including challenging personal circumstances, the pandemic, and Brexit-related supply pressures. However, it was emphasized that these external factors did not excuse the failure to implement necessary controls and systems.

Sanction
A two-month suspension was imposed. The committee considered that this was a proportionate response, balancing the need to uphold public confidence in the profession while recognizing the registrant’s remorse, insight, and steps taken to address past failings. An immediate interim suspension order was also enacted until the final date of effect or resolution of any appeal.

Key Learning Points for Pharmacy Professionals

1. Robust SOP Implementation: SOPs are foundational to safe pharmacy practice. They must be up-to-date, signed, and understood by all staff. Version control and clear authorship are vital.
2. Audit and Monitoring of High-Risk Medicines: Codeine Linctus and similar medicines require strict oversight due to their misuse potential. Pharmacies must implement systems to track, audit, and justify procurement and sale.
3. Professional Judgment and Diligence: Even in busy settings or during crises (e.g., pandemic or Brexit-related disruptions), pharmacists must maintain professional standards and make decisions grounded in public safety.
4. Importance of Accountability: The role of Superintendent Pharmacist carries overarching responsibility. Delegation must be coupled with monitoring and oversight.
5. Learning from Failures: Proactive steps such as CPD, process revision, and accepting responsibility can be mitigating but must be timely and comprehensive.

This case serves as a cautionary example of how inadequate governance, even when not resulting in direct harm, can lead to professional impairment and regulatory action. Pharmacy professionals must remain vigilant, structured, and accountable, particularly when handling medicines with high misuse potential.

Original Case Document

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