Pharmacy Technician Suspended for TPN Errors and Discriminatory “Mong” Remarks Towards Colleague with Autism

Date of Decision: October 29, 2025

Registrant's Role: Pharmacy technician

Allegations:

On 29 July 2019, incorporated errors into work by selecting incorrect ingredients for TPN products prescribed to patients PB and GW.
Allegedly made these errors deliberately to undermine a colleague.
Put patients at risk of receiving incorrectly formulated TPN products.
On one or more occasions, made discriminatory comments and/or demonstrated bullying behaviour towards a colleague, referring to him as a "mong".

Outcome: Suspension for 4 months

GPhC Standards Breached:

Standard 6 – Pharmacy professionals must behave in a professional manner; treat people with respect and safeguard their dignity.
Standard 9 – Pharmacy professionals must demonstrate leadership, take responsibility for their actions, and lead by example.

Case Summary

Allegations

The case against the registrant, a pharmacy technician, centred on two serious allegations. First, the registrant was involved in errors during the preparation of Total Parenteral Nutrition (TPN) products for two patients on 29 July 2019. These errors involved selecting incorrect ingredients, which could have led to the administration of improperly formulated nutritional therapy—an especially critical matter given the intravenous nature of TPN, which is used in patients who cannot receive nutrition through normal digestion. The concern was not only about the errors themselves but the allegation that they were committed deliberately to sabotage a colleague’s competency assessment.

Secondly, the registrant was accused of making repeated derogatory comments towards a colleague, referred to as “Colleague 2”, who has autism. These comments included referring to the colleague as a “mong” on multiple occasions, which the complainant described as aggressive and demoralizing behaviour.

Findings

The committee found that while the errors in the TPN preparation were indeed made, it could not determine with sufficient certainty that they were deliberate. The registrant had completed “Reflection on Errors” forms at the time and claimed to have been rushing due to personal pressures. The committee concluded there was insufficient evidence to prove intent, stating:

“There was not sufficient evidence before it to be satisfied on the balance of probabilities, that what the Registrant did was deliberate.”

However, the second allegation regarding discriminatory language was found proven. Colleague 2 testified consistently, both in written and oral statements, that the registrant referred to him using the slur “mong” regularly, estimating it occurred four to five times per week. This term, known to be derogatory and historically used to demean individuals with intellectual disabilities, was especially harmful given the colleague’s autism. The registrant denied using the term but admitted to participating in workplace “banter” that “possibly was not appropriate”. The committee accepted Colleague 2’s account and found the conduct both discriminatory and bullying.

GPhC Determination on Impairment

The committee concluded that the registrant’s fitness to practise was impaired due to misconduct. The use of discriminatory language towards a colleague with a known disability was considered a significant breach of professional standards, particularly:

Standard 6, which mandates professional, respectful behaviour and safeguarding of dignity;
Standard 9, which calls on pharmacy professionals to lead by example.

The committee found that the misconduct posed a risk to public confidence and breached fundamental principles of the profession. Although the registrant offered some reflections suggesting personal difficulties at the time and acknowledged being irritable, the committee noted a lack of compelling evidence of genuine remediation or insight.

It also considered the lack of engagement from the registrant, who had not participated in the hearing, had not submitted any testimonials or evidence of ongoing professional development, and expressed intent to leave the register in prior correspondence. This limited the committee’s ability to assess whether the registrant had taken steps to address the misconduct.

Sanction

The committee imposed a four-month suspension. It concluded that this duration was proportionate to:

Mark the seriousness of the discriminatory conduct,
Allow the registrant time to reflect and remediate,
Protect public confidence in the profession.

The committee deemed that a more lenient outcome, such as a warning or conditions of practice, would be inadequate due to the registrant’s lack of engagement and the risk of repetition. However, it also considered that full removal from the register would be disproportionate, given the misconduct was remediable and there was some evidence of reflection, albeit limited.

The committee stated:

“A short suspension of four months would be sufficient for the Registrant to reflect and remediate his conduct should he wish to do so.”

The suspension is subject to review, and the committee outlined that a future panel would benefit from the registrant’s attendance, a reflective statement, evidence of training in equality and diversity, and professional testimonials.

Key Learning Points for Pharmacy Professionals

Language Matters: Even casual use of derogatory terms can amount to serious misconduct, particularly when directed at colleagues with known disabilities. Pharmacy professionals must maintain respectful and inclusive communication at all times.
Workplace Culture Is Not a Defence: Even if certain language or behaviours are common in a workplace, they do not excuse unprofessional conduct. Pharmacy professionals are expected to uphold standards regardless of peer behaviour.
Insight and Engagement Are Critical: Demonstrating understanding of past misconduct, showing remorse, and actively engaging with regulatory proceedings are essential steps in rebuilding trust and maintaining registration.
Bullying Undermines Professionalism: Hierarchical or supervisory relationships carry a duty of care. Professionals must support junior or less experienced colleagues, not belittle them.
Medication Handling Must Be Flawless: Although the more serious allegation of deliberate errors was not proven, this case underscores the critical nature of accuracy in compounding and dispensing—especially with high-risk products like TPN.

This case serves as a stark reminder that professionalism extends beyond technical competence. Attitudes, behaviour, and workplace interactions are equally subject to scrutiny and carry significant weight in determining fitness to practise.

Original Case Document

The full determination transcript is available to logged in users.