Superintendent Pharmacist Warned Over Lapses in Online Pharmacy Governance and Controlled Drug Wholesale Export

Date of Decision: October 14, 2025

Registrant's Role: Pharmacist

Allegations:

Failed to manage risks associated with online pharmacy services, particularly regarding medicines liable to abuse, overuse, or misuse.
Did not ensure adequate systems or safeguards for medicines requiring ongoing monitoring.
Supplied large quantities of medication to North America without confirming legality or having appropriate indemnity insurance.
Supplied medication without possessing the required wholesale distribution licence.

Outcome: Warning issued (published on the register for 12 months)

GPhC Standards Breached:

Standard 1 – Provide person-centred care.
Standard 2 – Work in partnership with others.
Standard 5 – Use their professional judgement.
Standard 9 – Demonstrate leadership.

Case Summary

Allegations

This case revolves around serious allegations concerning the registrant’s conduct during her tenure as Superintendent Pharmacist (SI) at Dock Pharmacy in Tilbury, Essex, from February to June 2021. The core concern relates to the registrant’s failure to appropriately oversee and manage the risks associated with the pharmacy’s online operations.

During this period, the pharmacy supplied significant volumes of medicines, including those liable to abuse, overuse, or misuse, such as products containing codeine, to customers in North America, notably the USA, and Nigeria. Critically, some of these medications, like codeine, are banned or strictly regulated in destination countries such as the USA.

The registrant did not ensure:

That the supply of medicines was legally compliant in the receiving countries.
That indemnity insurance covering such international activities was in place.
That the pharmacy held the appropriate wholesale distribution licence necessary for supplying medicinal products to organisations.

Furthermore, there was a lack of robust systems and safeguards for managing medication requiring ongoing monitoring and a general failure to ensure the safe operation of distance-selling pharmacy services.

Findings

While the registrant argued she had only assumed the SI role temporarily and reluctantly, the Committee was unequivocal in its finding that the responsibilities of an SI cannot be delegated or diminished, regardless of the extent of daily operational involvement. She had submitted documentation to be listed as the SI and thus held legal and professional responsibility for all pharmaceutical activities undertaken by the pharmacy, including online services.

There was no suggestion of malicious intent or direct involvement in unsafe dispensing; however, the failure to discharge the duties of the SI role adequately posed a real risk to public and patient safety. As the GPhC emphasised:

“The Registrant ought to have known as SI, that she was responsible for all pharmaceutical activities at the Pharmacy including the online pharmacy business, and that she could not agree to absolve herself of that responsibility in the role of SI.”

The panel found these failures particularly concerning because they occurred over a prolonged period and in a context involving international medicine supply, requiring heightened diligence and compliance.

GPhC Determination on Impairment

The panel considered that the registrant’s actions constituted a breach of multiple GPhC standards, specifically:

Standard 1: failing to provide safe, person-centred care through proper systems.
Standard 2: lack of effective collaboration in ensuring legal compliance.
Standard 5: failure to exercise sound professional judgement.
Standard 9: poor leadership, especially in a regulated senior role.

The breaches presented an actual or potential risk to patient safety and undermined public confidence in the pharmacy profession. The panel determined that the registrant’s conduct, though not malicious, demonstrated a significant departure from accepted professional standards and merited regulatory response.

Sanction

Given the seriousness of the breaches and the professional accountability inherent to the SI role, the GPhC Investigating Committee issued a formal warning. This warning will remain visible on the public register for 12 months. While a more severe sanction was not deemed necessary—likely due to lack of direct harm and the registrant’s eventual cooperation—this outcome underscores the gravity with which such lapses are viewed.

The warning includes specific expectations for the registrant, stating:

“The Registrant is warned that she must ensure that she fully understands the duties and responsibilities of any professional roles that she undertakes and is able to perform them adequately.”

It also reiterates legal requirements such as:

The necessity of holding a wholesale licence when supplying medication to organisations.
The requirement for appropriate indemnity insurance.
The need for robust systems and monitoring, especially for medicines prone to misuse.

Key Learning Points for Pharmacy Professionals

Superintendent Pharmacist Accountability: The role of SI carries non-delegable responsibility for all regulated activities. Simply being unaware of operations or acting as a placeholder does not absolve responsibility.
Distance Selling Risk Management: Supplying medication across borders demands meticulous attention to local legal frameworks, insurance cover, and controlled drug regulations.
Controlled Drug Oversight: Medications like codeine, even if available in the UK, may be restricted abroad. Pharmacists must understand these differences to avoid illegal supply.
Regulatory Documentation: Pharmacists must not submit or accept regulatory designations (e.g., SI registration) without full comprehension and readiness to discharge their legal and professional duties.
Systemic Safeguards in Online Pharmacies: Online and distance-selling services require rigorous systems, policies, and clinical governance. Lapses can result in unmonitored supply of high-risk medications.

This case is a compelling reminder that clinical governance and legal compliance are not optional extras, particularly in senior leadership roles. Pharmacy professionals must ensure they are not only aware of but actively managing the responsibilities they accept.

Original Case Document

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