Superintendent Pharmacist Struck Off After Serious Controlled Drug Governance Failures in Cannabis-Based Medicines Pharmacy
Date of Decision: March 17, 2026
Registrant's Role: Pharmacist
Allegations:
- Operating without adequate governance systems such as risk assessments for services provided
- Failure to maintain records verifying that CBPMs were appropriately prescribed
- Supplying high-risk medicines to potentially vulnerable patients without safeguarding procedures or training
- Allowing an untrained, unregistered company director to work alone in the pharmacy
- Pre-signing dispensing labels not yet attached to medicines
- Repeatedly operating without a Responsible Pharmacist (RP) present or properly recorded
- Inadequate RP log entries, including missing and incomplete records
- Supplying medicines when no RP was recorded on duty
- Unsafe management of controlled drugs, including:
- Late entries in CD registers (both supplied and received)
- CD entries recorded when no RP was present
- CD register entries made by an untrained/non-registered individual
- Missing corresponding entries in the private prescription register
- Failure to identify or challenge multiple prescriptions from different prescribers for the same patients
- Failure to store Schedule 2 CDs and CBPMs in a controlled drug cabinet
Outcome: Removal from the register with an interim suspension imposed pending the appeal period
GPhC Standards Breached:
- Standard 1 – Provide person-centred care
- Standard 2 – Work in partnership with others
- Standard 5 – Use professional judgement
- Standard 6 – Behave in a professional manner
- Standard 7 – Respect and maintain confidentiality and privacy
- Standard 8 – Speak up when there are concerns or when things go wrong
- Standard 9 – Demonstrate leadership
- Standard 10 – Work effectively within teams
- Standard 11 – Ensure safe and effective governance
Case Summary
Allegations
This case concerns a Superintendent Pharmacist responsible for a pharmacy specialising in cannabis-based medicinal products (CBPMs), many of which are Schedule 2 controlled drugs and largely unlicensed medicines requiring heightened regulatory oversight.
Between February 2021 and May 2022, the pharmacy operated with widespread and systemic governance failures. The registrant failed to implement even basic safeguards expected in pharmacy practice. There was no documented risk assessment for services, and critically, no reliable system to verify whether CBPM prescriptions were appropriate or legitimate. This is particularly significant given that CBPMs require prescribing by specialist clinicians and careful monitoring due to their psychoactive potential and abuse risk.
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- Full allegations considered by the GPhC
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- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
- Details of the pharmacy professionals involved