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

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.