Superintendent Pharmacist Sanctioned for Unsafe Online Dispensing and Regulatory Breaches

Date of Decision: May 6, 2025

Registrant's Role: Pharmacist

Allegations:

Failure to maintain and retain private prescription records in accordance with Regulation 253 of the Human Medicines Regulations 2012.
Failure to complete private prescription records accurately and on time.
Non-compliance with pharmacy SOPs for private prescription recording.
Dispensing medicines without supervision or the knowledge of the Responsible Pharmacist.
Continuing unsafe online supply of POMs including controlled drugs despite warnings from the regulatory authority.
Misleading the Society about cessation of online services.
Failing to maintain safe, effective, and transparent pharmacy operations across multiple premises.

Outcome: Conditions Order extended for 6 months from 10 May 2025, prohibiting the registrant from acting as Superintendent Pharmacist and requiring ongoing oversight and reporting.

GPhC Standards Breached:

Standard 1 – Putting patients first
Standard 2 – Providing a quality service
Standard 3 – Acting with professionalism and integrity

Case Summary

Allegations

The registrant, acting as Superintendent Pharmacist of Wynrose Limited, faced serious allegations concerning failures in the management and oversight of private prescription dispensing through an online platform. Between November 2019 and September 2020, multiple regulatory breaches occurred. Most critically, prescription-only medicines—including Schedule 4 and 5 controlled drugs such as dihydrocodeine, codeine phosphate, solpadol, co-codamol, and zolpidem—were dispensed without appropriate supervision.

The pharmacy’s SOPs were ignored, private prescription records were either missing or completed retroactively (sometimes falsely indicating supply dates when the pharmacy was closed), and medicines were dispensed without Responsible Pharmacist (RP) oversight. On 23 January 2020, 32 private prescriptions were dispensed at McFaddens Pharmacy without the knowledge or clinical input of the Responsible Pharmacist. This was facilitated under the registrant’s direction and knowledge, despite the RP explicitly being told she was not involved in the online service.

Furthermore, even after being explicitly warned by Joe Brogan, Head of Pharmacy and Medicines Management, HSCB, in February 2020 regarding safety concerns and therapeutic duplication risks, the registrant assured regulators that the service ceased by June 2020. However, it resumed weeks later and continued until September 2020—indicating a deliberate act driven by commercial motivations.

Findings

The Committee found that the registrant’s actions demonstrated a sustained failure to meet essential professional and regulatory responsibilities. The dispensing system allowed patients to receive potent medications without GP involvement or appropriate scrutiny, a practice that posed a significant risk to patient safety. The registrant used her login credentials to facilitate unauthorized entries, and non-pharmacists were also found to be making prescription log entries under pharmacist names, undermining data integrity.

At a prior hearing, the Committee concluded the registrant’s “integrity can no longer be relied upon” and criticized her for covert operations, misleading assurances, and prioritizing commercial over professional obligations. The panel cited a quote from the registrant’s June 2020 communication to the Society:

“Wynrose Ltd are no longer dispensing any online prescriptions for Better Health online ordering system and do not intend doing so.”

Despite this assurance, the online operations recommenced the next month. The registrant’s conduct was found to have violated the principles of patient-centred care, integrity, and accountability.

GPhC Determination on Impairment

The Statutory Committee repeatedly reviewed the registrant’s fitness to practise across multiple hearings. Initially, in January 2023, a 12-month suspension was imposed due to the gravity of her misconduct. At subsequent reviews in February 2024 and April–May 2024, the registrant failed to adequately demonstrate full insight or sufficient remediation.

Although she showed some improved reflection, including an apology to the RP and acknowledgment of the patient safety failures, the Committee considered her actions too reactive and driven by external prompts, rather than proactive professional development. The registrant’s tendency to focus on business survival over ethical and regulatory compliance persisted as a concern.

At the third review on 6 May 2025, the registrant again failed to meet the burden of proof to demonstrate complete remediation. Notably, she failed to provide timely reports from the newly appointed Superintendent Pharmacist, and there were continued doubts about her understanding of governance roles.

Sanction

Given the continued impairment of fitness to practise, the Committee extended the existing Conditions Order for a further 6 months. The registrant remains prohibited from acting as Superintendent Pharmacist and must:

Maintain role distinction between herself and the Superintendent Pharmacist.
Submit signed reports confirming effective governance and safe practice.
Notify the Pharmaceutical Society NI of any professional appointments.
Continue working with a mentor (though not mandated, voluntary reporting is encouraged).

The Committee emphasized the need for tangible, proactive actions rather than stated intentions. They concluded that a suspension was no longer proportionate but maintained strict oversight through enforceable conditions.

Key Learning Points for Pharmacy Professionals

Supervision is Non-Negotiable: Medicines—especially controlled drugs—must never be dispensed without the knowledge, presence, and control of the Responsible Pharmacist. Any deviation from this principle risks patient safety and breaches professional standards.
Records Must Be Accurate and Contemporaneous: Retrospective and falsified prescription logs, particularly when backdated or entered by unqualified personnel, undermine public trust and regulatory compliance.
SOPs Are Binding, Not Optional: Ignoring established SOPs reflects a fundamental breakdown in governance. Pharmacy leaders must ensure that SOPs are followed and audited regularly.
Patient Safety Over Business Interests: Prioritizing commercial considerations at the expense of clinical standards is a grave error. The Committee found that the registrant’s decisions were commercially motivated, breaching core ethical duties.
Insight Must Be Demonstrated, Not Declared: Remediation requires verifiable actions—training, process changes, mentoring—not merely intentions or acknowledgments. Demonstrating genuine insight includes owning past misconduct and actively working to prevent recurrence.
Transparency with Regulators is Critical: Misleading regulatory bodies, or providing false assurances, erodes confidence and may aggravate sanctions. Open, honest, and timely communication is essential for all pharmacy professionals.

This case underscores the importance of rigorous governance, professional integrity, and patient-centred practice in all areas of pharmacy, especially when navigating novel service models such as online dispensing.

Original Case Document

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