Pharmacy Technician Suspended for Unsafe CDS Dispensing Practices and Record Keeping Failures

Date of Decision: June 24, 2019

Registrant's Role: Pharmacy technician

Allegations:

Dispensed Community Dosage System (CDS) medications without a valid prescription from around December 2015 to November 2016.
Dispensed CDS medications without a pharmacist check during the same period.
Failed to ensure proper record keeping of CDS prescriptions and medications dispensed.

Outcome: Suspension from the register for 4 months

GPhC Standards Breached:

Standard 1.1 – Make sure the services you provide are safe and of acceptable quality
Standard 1.2 – Take action to protect the well-being of patients and the public
Standard 1.4 – Get all the information you require to assess a person’s needs
Standard 1.6 – Provide medicines and services safely and when needed
Standard 1.8 – Keep full and accurate records
Standard 2.1 – Act in the best interests of patients and the public
Standard 2.2 – Ensure professional judgment is not affected by external factors
Standard 5.1 – Recognise the limits of your professional competence
Standard 5.2 – Maintain and improve the quality of your practice
Standard 5.3 – Apply your knowledge and skills appropriately
Standard 5.4 – Learn from assessments and undertake further training
Standard 5.5 – Undertake and document continuing professional development

Case Summary

Allegations

The case revolved around a pharmacy technician who, over an extended period between December 2015 and November 2016, was found to have engaged in a series of unsafe and improper dispensing practices. Key among these were:

Dispensing medication from the Community Dosage System (CDS) without prescriptions.
Failing to secure pharmacist checks on the medication she dispensed.
Not keeping adequate records of prescriptions or medications dispensed.

These practices led to concerns not just about patient safety, but also about the integrity of pharmacy operations and professional standards. The investigation stemmed from internal audits and a Clinical Commissioning Group complaint, which identified serious non-compliance with both SOPs and GPhC standards.

Findings

The GPhC panel found that the pharmacy technician routinely dispensed medications without a valid prescription and often without a pharmacist’s check. She also admitted in various interviews that some medications were issued based on previous prescriptions or assumed approval, often relying on relationships with GP surgeries rather than following formal processes. She was also found to have altered dates on old backing sheets and reused them, bypassing the PMR entirely.

Critically, despite having worked at the pharmacy for 24 years and acknowledging SOPs by signing a Record of Competence form, she failed to implement the required safety checks and documentation protocols.

The panel noted:

“We accept that the Pharmacy may have been busy, and was understaffed, but this is not a justification for what she did.”

The breach in standards was not an isolated incident but part of a recurring pattern that lasted several months and involved around 20 patients, raising serious concerns about patient risk and professional negligence.

GPhC Determination on Impairment

The panel found that the registrant’s misconduct was serious and persistent, falling significantly below the standards expected of a pharmacy technician. Although she believed that faxed prescriptions were legal instruments for dispensing, this was found to be a significant misunderstanding with patient safety implications.

The registrant showed limited insight into her actions, maintained during the hearing that her work was properly checked by a pharmacist, and did not fully acknowledge the gravity of her procedural breaches.

Despite no evidence of actual patient harm, the panel considered the risks substantial due to the failure to follow essential safety protocols.

Sanction

The panel imposed a suspension order on the pharmacy technician’s registration. They emphasized the need to uphold public trust in the pharmacy profession and protect patient safety. While the registrant had no prior Fitness to Practise history and showed commitment by continuing to seek pharmacy roles, her failure to fully accept responsibility and demonstrate insight into her misconduct influenced the decision.

The panel remarked:

“Although Conditions of Practice could be formulated to protect the public, in light of the lack of insight, and in order to mark the public interest, a period of suspension is required.”

Key Learning Points for Pharmacy Professionals

Prescriptions Are Mandatory: No medication should be dispensed without a valid prescription, even in cases involving CDS or urgent needs. Emergency supplies must be documented and followed up with a valid prescription within 72 hours.
Faxed Prescriptions Are Not Legally Valid: Even if signed, faxed copies do not meet legal requirements for dispensing and must not replace original prescriptions.
Pharmacist Checks Are Essential: Pharmacy technicians, including ACTs, cannot check their own work or dispense without appropriate pharmacist oversight.
Documentation Matters: Accurate and timely PMR entries are vital for continuity of care, auditing, and regulatory compliance.
SOP Adherence Is Non-Negotiable: Deviations from SOPs, even under operational pressure or with good intentions, undermine patient safety and professional standards.
Insight and Remediation Are Key: Understanding the impact of professional failings and taking meaningful steps to address them are critical for maintaining trust and restoring fitness to practise.

This case highlights the serious implications of operational shortcuts and underlines the importance of consistent adherence to pharmacy laws and ethical standards, even under challenging workplace conditions.

Original Case Document

The full determination transcript is available to logged in users.