Pharmacist’s Conditions Extended Due to Incomplete Remediation of Dispensing and Controlled Drug Errors

At the original hearing, the registrant was found to have committed a pattern of errors related to the handling and dispensing of controlled drugs (CDs), including:

• Making non-chronological entries in CD registers for drugs like MST and Oxycontin.
• Incorrectly recording or failing to record CD deliveries.
• Dispensing the wrong quantity (e.g. 60 MST instead of 56).
• Advising a colleague to dispense Temazepam without a prescription.
• Failing to inform superiors of errors and not reading or following SOPs.

At the review hearing in April 2020, the registrant had been under a 12-month conditional order, requiring audits, reflective diaries, supervision, and training. The review assessed whether the registrant had demonstrated full remediation.

Findings

The committee found that the registrant:

• Had made some progress (e.g. completing a return-to-practice course and working under supervision).
• Failed to comply fully with the conditions — particularly in:
  • Auditing all dispensing errors and reporting them clearly.
  • Reflecting meaningfully in the diary about how errors occurred and were addressed.
  • Discussing all audited errors with their supervisor, including significant incidents like methadone being dispensed on the wrong day.

Examples from the committee:

“The diary did not record all of the errors listed in his own audits… many entries amounted to summary notes of general events of the day, e.g. ‘boring day’.”

“There remains a risk of repetition… a potential risk to patients or the public.”

The committee accepted that the registrant had shown some insight and perseverance, and had received positive testimonials. However, it was not convinced that the registrant had taken a sufficiently rigorous approach to audits or reflection.

GPhC Determination on Impairment

• Fitness to practise remains impaired.
• Risk of harm to patients due to incomplete compliance with CD safety measures.
• Misunderstanding or downplaying the seriousness of errors – e.g. excluding a methadone error from an audit because he didn’t consider it a “dispensing error.”

The committee concluded that the registrant had not yet met the standard required to lift the restrictions.

Sanction

• The existing conditions were extended for another six months.
• Changes were made to clarify expectations:
  • Monthly audits and supervisor reports (instead of quarterly).
  • Improved clarity around reflection and error documentation.
  • Reconfirmation that the registrant must not work as a superintendent or sole practitioner.

No suspension was issued, with the committee stating:

“A more severe sanction would be disproportionate… a further period under conditions gives the registrant the opportunity to fully demonstrate remediation.”

Key Learning Points for Pharmacy Professionals

1. Full compliance with remediation conditions is essential – Partial effort may not satisfy a review committee.
2. Controlled Drug errors are taken seriously – Even minor record-keeping mistakes must be logged and reflected upon.
3. Reflective practice requires depth – Generic entries or vague statements are not enough.
4. Insight includes recognising all types of errors – Omitting a methadone error due to misclassification shows a lack of understanding.
5. Supervision and audits must be structured and comprehensive – Casual, end-of-day discussions are insufficient for regulatory oversight.

Conclusion

This case highlights how even after a successful return to practice, pharmacy professionals must meet all requirements rigorously to remain on the register unrestricted. The GPhC granted a further six-month conditional order to give the registrant the opportunity to prove full remediation and regain unrestricted fitness to practise.