Specialist Mental Health Pharmacist Allowed to Practise Unrestricted After Successful Remediation

Date of Decision: June 1, 2020

Registrant's Role: Pharmacist

Allegations:

Failed to document or communicate a known contraindication (carbamazepine with clozapine) for a patient.
Failed to complete medicines reconciliation on hospital admission.
Failed to adequately check prescription charts and Mental Health Act forms across multiple patients.
Led to unauthorised or incorrect medication administration for several patients.
Recorded incorrect BNF code and missed omissions in urgent treatment documentation.

Outcome: Previously subjected to 18-month conditional registration

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 5 – Use professional judgement
Standard 6 – Behave in a professional manner
Standard 9 – Demonstrate leadership

Case Summary

Original Allegations and Findings (2018 Determination)

While working as a Specialist Mental Health Pharmacist, the registrant was found to have:

Failed to disclose or act upon a dangerous drug interaction: she did not document that a patient on clozapine was also receiving carbamazepine, a contraindicated medicine.
Omitted essential medicines reconciliation for a newly admitted patient.
Failed to verify prescription charts, resulting in patients receiving medications at incorrect frequencies or lacking records of important treatments.
Failed to check Mental Health Act forms (T2, T3, and section 62 forms), resulting in unauthorised prescribing and administration in several cases.
In one case (Patient N), she failed to notice a missing entry for clonazepam on a Section 62 form and recorded an incorrect BNF code.

The 2018 panel found the registrant’s actions amounted to misconduct and deficient professional performance and imposed an 18-month conditions of practice order, with a review scheduled.

Conditions Imposed (2018–2020)

The conditions required the registrant to:

Limit her scope of practice (no locum, community, or mental health specialist work).
Undertake further training in clinical areas including interactions, communication, leadership, and mental health law.
Work under supervision and submit regular progress reports and development plans.
Avoid pre-registration supervision roles and not employ or train undergraduates.

Review and Decision (2020 Hearing)

By the 2020 review hearing, the registrant had:

Complied fully with all conditions over the 18-month period.
Provided multiple reflective pieces, including a detailed second reflection showing clear insight.
Completed relevant CPD and training, including placements with mental health pharmacy teams.
Received strong testimonials from supervisors and colleagues describing her as reliable, insightful, and a leader.
Successfully worked in an Advanced Pharmacist secondment, leading a team during the COVID-19 pandemic.

“She has maintained a very strong professional attitude… her work has always met or exceeded expectations.”
“She is a much-loved member of our team and a passionate advocate of the profession.”

The committee concluded that the registrant had:

Demonstrated full insight and reflection.
Addressed all previously identified concerns.
Grown in leadership, clinical safety awareness, and accountability.

GPhC Determination on Impairment

The Committee found that:

The registrant no longer posed a risk to patient safety.
There was no ongoing impairment.
She had remediated both her misconduct and performance deficiencies to a high standard.

“The Registrant has complied with the conditions imposed… That is very much to her credit.”

Sanction

The 18-month conditions order was allowed to expire without renewal. No further action was taken.
The registrant is now fully restored to unrestricted practice.

Key Learning Points for Pharmacy Professionals

Specialist roles demand specialist competence—pharmacists must recognise the limits of their training and seek support where needed.
Failure to check charts and legal documentation (e.g. Mental Health Act forms) can result in unsafe, unauthorised treatment.
Deficient performance can be remediated—through education, insight, and supervised practice.
Reflective practice and mentorship are powerful tools for professional development and restoration.
Leadership and safety culture are essential, especially in hospital and mental health settings.

Conclusion

This case shows that even serious errors in clinical judgement and documentation—if acknowledged and addressed—do not have to end a pharmacist’s career. Through structured remediation, supervision, and insight, the registrant demonstrated that she could return to unrestricted practice, having learned from past failures and grown as a pharmacy professional.

Original Case Document

The full determination transcript is available to logged in users.