Superintendent Pharmacist Warned for Failing to Maintain Any CD Registers
Date of Decision: August 26, 2025
Registrant's Role: Pharmacist
Allegations:
- Failure to maintain a controlled drugs (CD) register while dispensing Schedule 2 controlled drugs.
- Failure to manage and assess risks associated with controlled drug handling as Superintendent Pharmacist.
- Breach of statutory responsibilities under the Misuse of Drugs Regulations 2001.
Outcome: Warning issued and published on the GPhC register for 12 months.
GPhC Standards Breached:
- Standard 2 – Pharmacy professionals must work in partnership with others.
- Standard 5 – Pharmacy professionals must use their professional judgement.
- Standard 8 – Pharmacy professionals must speak up when they have concerns or when things go wrong.
- Standard 9 – Pharmacy professionals must demonstrate leadership.
Case Summary
Allegations
This case concerns the conduct of the registrant, a Superintendent Pharmacist at a retail pharmacy, between January 2023 and 25 September 2023. During this period, the pharmacy routinely dispensed controlled drugs, including those classified under Schedule 2 of the Misuse of Drugs Act 1971. Despite the high-risk nature of these medications, the pharmacy did not have a controlled drugs (CD) register in place, in breach of the Misuse of Drugs Regulations 2001 (as amended). The responsibility for overseeing this critical aspect of pharmacy governance rested squarely with the registrant.
As the Superintendent, the registrant was expected to assess, manage, and record risks associated with the handling of CDs, and ensure that robust systems were implemented for safe and compliant pharmacy operations. The absence of a CD register represented a significant failing in risk management, regulatory compliance, and leadership.
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- Full allegations considered by the GPhC
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- Key professional learning points
Original Case Document
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