Superintendent Pharmacist Faces Extended Restrictions After Failures in Governance Over High-Risk Codeine and Phenergan Supply
Date of Decision: March 3, 2026
Registrant's Role: Pharmacist
Allegations:
- Failed to ensure that up-to-date Standard Operating Procedures (SOPs) were in place covering the sale and supply of high-risk opioid medicines at either pharmacy.
- Ordered and/or permitted the ordering of large quantities of Codeine Linctus, including: 50 × 200ml bottles on 3 October 2019 (Your Prescriptions Ltd); 100 × 200ml bottles on 21 October 2019 (Your Prescriptions Ltd); 48 × 200ml bottles on 5 November 2019 (Your Prescriptions Ltd); 36 × 200ml bottles on 5 November 2020 (Al Shafa Pharmacy); 24 × 200ml bottles on 19 November 2020 (Al Shafa Pharmacy); 24 × 200ml bottles on 30 November 2020 (Al Shafa Pharmacy); 24 × 200ml bottles on 2 December 2020 (Your Prescriptions Ltd)
- Ordered and/or permitted the ordering of large quantities of Phenergan Elixir, including: 50 × 100ml bottles on 13 November 2019 (Al Shafa Pharmacy); 30 × 100ml bottles on 2 September 2020 (Your Prescriptions Ltd); 30 × 100ml bottles on 19 November 2020 (Al Shafa Pharmacy); 28 × 100ml bottles on 23 November 2020 (Al Shafa Pharmacy); 24 × 100ml bottles on 30 November 2020 (Al Shafa Pharmacy); 56 × 100ml bottles on 30 November 2020 (Your Prescriptions Ltd)
- Failed to have adequate systems in place to monitor or audit the ordering of Codeine Linctus and Phenergan Elixir, both of which are high-risk medicines liable to misuse, overuse, and abuse (including misuse by mixing together).
- Failed to have adequate systems to monitor or audit the sale and supply of these high-risk medicines.
- Ordered or permitted the ordering of 300 packs of Codeine Phosphate 60 mg tablets (28-tablet pack size) on or around 4 December 2019.
- Ordered or permitted the ordering of 500 packs of Co-codamol 30/500 mg tablets (100-tablet pack size) on or around 17 June 2020.
Outcome: Revised Conditions of Practice imposed for 12 months following a review hearing.
GPhC Standards Breached:
- Standard 1 – Provide person-centred care
- Standard 6 – Behave professionally
- Standard 7 – Respect and maintain the person’s confidentiality and privacy
- Standard 8 – Speak up when you have concerns or when things go wrong
- Standard 9 – Demonstrate leadership
Case Summary
Allegations
This case concerns a pharmacist who held senior professional responsibilities, including serving as Superintendent Pharmacist for two community pharmacies and acting as the regular Responsible Pharmacist at one of them. The case focused primarily on governance failures relating to the management and oversight of high-risk medicines, particularly opioid-containing cough syrups and antihistamine preparations commonly associated with misuse.
The regulator investigated the registrant’s ordering and governance practices in relation to medicines such as Codeine Linctus and Phenergan Elixir. These products are known to carry a risk of misuse, particularly when combined recreationally in mixtures sometimes referred to as “lean” or “purple drank.” Because of this risk, pharmacies are expected to maintain strict governance controls, including appropriate ordering oversight, monitoring of sales patterns, and robust SOPs governing supply.
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- Full allegations considered by the GPhC
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Original Case Document
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