Pharmacist’s Fitness to Practise Impaired Due to Inappropriate Conduct During EHC Consultation

Date of Decision: April 16, 2019

Registrant's Role: Pharmacist

Allegations:

• In or around October 2017, while working as a locum pharmacist:
• The registrant touched Patient A’s breasts.
• The registrant asked Patient A to remove her dress.
• The registrant put his hands up Patient A’s dress.
• The registrant allowed Patient A to leave the pharmacy with Emergency Hormonal Contraception (EHC) unsupervised.
• Actions at 3(a), 3(b), and/or 3(c) were alleged to be sexually motivated.

Outcome: Removal from the register

GPhC Standards Breached:

• Standard 1 – Provide person-centred care.
• Standard 2 – Work in partnership with people.
• Standard 3 – Communicate effectively.
• Standard 6 – Behave professionally.
• Standard 9 – Demonstrate leadership.

Case Summary

Allegations:
The case centred on the conduct of a locum pharmacist during an Emergency Hormonal Contraception (EHC) consultation with Patient A in October 2017. It was alleged that during this private consultation, the pharmacist inappropriately touched the patient’s breasts, requested she remove her dress, and placed his hands up her dress to examine her groin area. Additionally, it was alleged that he allowed her to leave the pharmacy with EHC without observing her take the medication, in contravention of local policies requiring supervised administration. The core allegation was that these actions were sexually motivated, constituting a serious breach of professional and ethical standards.

Findings:
The panel found Patient A to be a consistent, credible, and reliable witness. Her account remained materially unchanged from the initial complaint to the hearing, and she gave clear testimony about the sequence of events. Her decision to return to the pharmacy the next day to make a complaint added to her credibility. In contrast, the registrant’s account was deemed inconsistent. He initially failed to recall creating an electronic patient record, only later asserting its existence mid-hearing. When the record was retrieved, it lacked the clinical detail he claimed to have documented (e.g., swollen armpits).

While the registrant claimed the physical contact was a response to the patient’s own request regarding armpit swelling, the panel found this explanation implausible given the absence of any such documentation or prior mention. Further undermining the registrant’s reliability were discrepancies in his layout diagram of the consultation room and his rationale for discussing breast cancer risks associated with EHC, which were unsupported by current evidence or guidance.

The Committee concluded that the registrant’s actions, including breast and groin touching during a non-clinically indicated examination, were deliberate and sexually motivated. The panel stated:

“The Committee was satisfied that the Registrant had touched Patient A’s breasts and groin without clinical justification and that his conduct was sexually motivated.”

GPhC Determination on Impairment:
The GPhC found the pharmacist’s fitness to practise impaired due to misconduct. The conduct was found to have fallen seriously short of the standards expected. The registrant abused a position of trust, compromised the dignity of a vulnerable patient, and caused emotional harm. The Committee emphasized the importance of maintaining public confidence in the profession and the regulatory process. The conduct demonstrated a lack of insight, and the panel noted the registrant’s failure to fully appreciate the gravity of his actions or acknowledge their impact.

Sanction:
The sanction imposed was removal from the register. The Committee determined that a lesser sanction such as suspension or a conditions of practice order would be insufficient to protect the public and uphold professional standards. The behaviour demonstrated fundamental failings incompatible with ongoing registration. The panel concluded that the registrant posed a risk to patients and the public and that erasure was the only proportionate response.

Key Learning Points for Pharmacy Professionals:

1. Respect for patient dignity and boundaries: Physical examinations in pharmacy practice must be clinically justified and conducted with full informed consent. Sensitive areas, such as breasts and groin, require exceptional care and, when possible, a chaperone.
2. Documentation is critical: Accurate, contemporaneous documentation supports clinical decisions and protects both patients and professionals. Failure to document clinical reasoning or actions raises significant concerns about credibility and transparency.
3. Supervision of medication administration: Pharmacists must adhere strictly to PGDs and local protocols regarding the dispensing and administration of EHC or any other medicines. Supervised administration requirements exist to safeguard patient health.
4. Sexual motivation in professional misconduct: Sexualised behaviour—whether overt or inferred—constitutes a severe breach of professional standards. The profession must remain vigilant to the misuse of clinical interactions for personal gratification.
5. Public trust and professional integrity: Any behaviour that undermines public confidence in pharmacists erodes the foundation of healthcare delivery. The profession holds a privileged position and must act with unwavering professionalism, even under pressure.

This case is a stark reminder that ethical lapses, particularly those involving patient vulnerability and trust, have grave consequences. Upholding the highest standards of conduct is not optional—it is the foundation of pharmacy practice.

Original Case Document

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