Pharmacist Suspension Extended for Unsafe Controlled Drug Practices and Police Caution in Third Review

Date of Decision: February 3, 2020

Registrant's Role: Pharmacist

Allegations:

• Supplied controlled drugs (diazepam, methadone, buprenorphine) without prescriptions.
• Failed to endorse FP10MDA prescriptions.
• Failed to maintain appropriate pharmacy records.
• Maintained inaccurate Responsible Pharmacist log.
• Received a police caution for unlawful possession of a large quantity of controlled drugs.
• Failed to notify the GPhC of the police caution within seven days.
• Was suffering from adverse physical or mental health.

Outcome: Suspension extended for 12 months

GPhC Standards Breached:

• Standard 1 – Provide person-centred care
• Standard 2 – Work in partnership with others
• Standard 3 – Communicate effectively
• Standard 4 – Maintain, develop and use professional knowledge and skills
• Standard 5 – Use professional judgement
• Standard 6 – Behave in a professional manner
• Standard 7 – Respect and maintain the person’s confidentiality and privacy
• Standard 8 – Speak up when they have concerns or when things go wrong
• Standard 9 – Demonstrate leadership

Case Summary

Allegations

The registrant, a pharmacist, was found to have committed a range of serious misconducts concerning the unsafe and unlawful handling of controlled drugs. Over an extended period in 2016, he supplied medication, including diazepam, methadone, and buprenorphine, to patients without valid prescriptions. Numerous regulatory breaches were identified during a Controlled Drugs Liaison Officer (CDLO) investigation triggered by concerns raised by a local GP surgery.

Failings included:

• Dispensing controlled drugs without prescriptions.
• Failing to properly endorse FP10MDA prescriptions.
• Inadequate record-keeping for supervised drug supplies.
• Omissions in the Controlled Drugs register.
• Inaccurate entries in the Responsible Pharmacist log.

The situation was compounded when, following a police investigation connected to a road traffic incident involving a former employee, a substantial amount of controlled drugs was found at the registrant’s home. He received a police caution for failing to ensure the safe custody of those drugs and failed to notify the GPhC of this within the required timeframe.

Additionally, the registrant was found to be suffering from adverse health, which was considered interlinked with the misconduct.

Findings

The initial hearing in February 2018 resulted in the registrant’s suspension for 12 months, with subsequent reviews extending it due to continued impairment. Throughout, the registrant admitted the factual particulars of the allegations. He accepted full responsibility, describing how difficult circumstances and personal stress, including a problematic relationship with a staff member and workplace turmoil, impacted his ability to manage the pharmacy.

Despite admitting to severe procedural failures such as “a very bad procedure” and “terrible” recording methods (e.g., using post-it notes for tracking controlled drugs), the panel recognised that the misconduct represented a serious breach of professional standards. The registrant’s actions were deemed to pose a significant risk to patient safety and public confidence in the pharmacy profession.

The police caution further demonstrated a lapse in his legal and ethical obligations. The registrant had not only stored controlled drugs improperly at home but had also failed to report the caution to the GPhC, a serious oversight.

GPhC Determination on Impairment

In each review hearing, the GPhC panel concluded that the registrant remained impaired on three grounds: misconduct, police caution, and health. The third review, held in February 2020, reiterated these conclusions. The panel cited a lack of meaningful remediation or engagement with the recovery process. While the registrant acknowledged his continued impairment and apologized for not meeting expectations, the panel emphasized the need to uphold public safety and professional standards.

The registrant’s own email to the GPhC, quoted in full during the determination, revealed his feelings of discouragement and helplessness:

“I was disappointed with the decision to re-suspend me a further 8 months… Receiving letters from them is unpleasant and can make me panic… Attending hearings, as I have done, without legal representation, I would not recommend to anyone.”

Despite these admissions, the panel found no substantial evidence of efforts to address the concerns previously raised.

Sanction

Given the persistent impairment and lack of remediation, the panel extended the registrant’s suspension for another 12 months. Lesser sanctions were deemed inappropriate, as they would not sufficiently protect the public or maintain confidence in the pharmacy profession.

The panel specifically noted:

• No evidence of completed CPD or training.
• No steps taken towards a Return to Practice course.
• Engagement with Pharmaceutical Defence and Listening Friends came too late to impact the current review.

While removal from the register was considered, it was ultimately judged disproportionate, given recent minimal progress. Instead, the panel emphasized the importance of structured and meaningful engagement in the next 12 months and set expectations for the next review hearing.

Key Learning Points for Pharmacy Professionals

1. Strict Compliance with Controlled Drug Regulations: Pharmacists must adhere rigorously to legal requirements concerning controlled drugs. Supplying such medications without prescriptions, or failing to keep appropriate records, poses significant risks to patient safety and professional integrity.
2. Record-Keeping is Non-Negotiable: Using informal methods like post-it notes for controlled drug tracking is unprofessional and dangerous. Accurate, timely documentation is fundamental to lawful and safe pharmacy practice.
3. Personal Relationships and Work Boundaries: Pharmacists should maintain professional boundaries in the workplace. Personal entanglements can undermine effective management and decision-making, especially in high-risk areas like controlled drug supply.
4. Prompt Disclosure of Criminal Sanctions: Failing to report a police caution, especially involving controlled substances, is a serious breach of professional responsibility. Transparency with the regulator is essential.
5. Mental Health and Fitness to Practise: Health issues impacting professional functioning must be addressed proactively. Support systems like Listening Friends are vital, but late engagement reduces their regulatory weight.
6. Insight and Remediation: Demonstrating reflection, undertaking CPD, and engaging with return-to-practice programs are key to showing fitness to return. Passive acceptance of suspension without evidence of progress does not satisfy regulatory expectations.

This case illustrates how failures in professional judgment, compounded by personal and health-related challenges, can severely impact a pharmacist’s career. It underscores the importance of proactive remediation, transparency, and commitment to safe practice.

Original Case Document

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