Suspended Sentence for NI Superintendent Pharmacist Following Prolonged Unlawful Supply of Controlled Drugs

Date of Decision: October 9, 2025

Registrant's Role: Pharmacist

Allegations:

• Criminal convictions relating to the unlawful supply and poor record keeping of multiple Schedule 2 controlled drugs (Co-codamol, Fentanyl, Tapentadol, Methylphenidate, Morphine, Oxycodone).
• Misconduct by failing to ensure the safe and effective supply of prescription-only medicines.
• Breach of interim conditions by accessing the pharmacy and PMR unsupervised and outside of working hours.

Outcome: Conditions imposed on registration for 18 months

GPhC Standards Breached:

• Standard 2.1 – Provide safe, effective and quality care
• Standard 2.3 – Record, store and process data clearly and accurately
• Standard 3.1 – Act with honesty and integrity at all times

Case Summary

Allegations

This case involves serious and sustained misconduct by the registrant, a superintendent pharmacist and director of Castlereagh Pharmacy Ltd, who was convicted of multiple criminal offences and found to have repeatedly breached professional standards and legal obligations. Between 2017 and 2020, the registrant unlawfully supplied significant quantities of prescription-only and controlled drugs, including Co-codamol, Fentanyl, Tapentadol, Methylphenidate, Morphine, and Oxycodone, without appropriate prescriptions and in breach of controlled drug record-keeping regulations.

A Medicines Regulatory Group (MRG) inspection first uncovered discrepancies in controlled drug registers (CDRs) and highlighted irregular dispensing practices, including the substitution of Yemex Fentanyl patches for the more expensive Mezolar brand prescribed. Investigators later discovered the sale of 300,500 Co-codamol tablets without prescriptions, with estimated profits ranging between £16,581.88 and £42,581.45. No patient records were kept for these sales, raising substantial concerns about diversion, misuse, and patient safety.

Despite being placed under interim conditions in July 2020—intended to safeguard public safety—the registrant accessed the pharmacy and its Patient Medication Records (PMRs) on 53 occasions out of hours and without supervision, clearly violating the agreed terms. He admitted the allegations and was sentenced in June 2024 to 11 months imprisonment, suspended for three years.

Findings

The Committee found the facts admitted and proven. The allegations were serious, involved criminal convictions, and covered misconduct over several years. Key findings include:

• The registrant supplied hundreds of thousands of Co-codamol tablets, classified as prescription-only, without valid prescriptions or any documentation.
• Controlled drug registers were either missing entries or had failed to reflect the actual supply and receipt of Schedule 2 drugs over extended periods.
• Falsified prescription submissions for Mezolar when Yemex patches were supplied suggested deliberate financial gain, even if modest.
• The registrant accessed the pharmacy and handled controlled drugs in violation of interim restrictions, reflecting disregard for regulatory orders and public safety.

The Committee noted:

“This was a routine and persistent course of conduct over an extended period of time which flouted the proper and purposeful restrictions on the sale of codeine and paracetamol containing products.”

GPhC Determination on Impairment

The panel assessed the registrant’s current fitness to practise and concluded it was impaired, both on public protection grounds and the need to maintain public trust in the profession. The decision referenced established legal principles, including those from Cohen v GMC and CHRE v NMC and Grant, emphasising the importance of looking forward and assessing insight, remediation, and recurrence risk.

While the registrant demonstrated some insight and remorse, he failed to reflect meaningfully on the impact of his actions on patients, such as the dangers of unlabelled high-dose codeine-paracetamol combinations and risks of overdose. He admitted to a lack of any “robust assessment process” before supplying such medicines. His decision to breach interim conditions was also viewed as particularly damaging.

Sanction

Despite the gravity of the offences and misconduct, the Committee decided not to remove the registrant from the register or impose a suspension. Instead, an 18-month conditions of practice order was issued. The rationale included:

• The registrant had complied fully with a revised set of 19 conditions since May 2021.
• He had worked safely under supervision for over four years with no further incidents.
• His current superintendent pharmacist gave strong evidence of support and ongoing monitoring.
• The registrant has undertaken relevant training and demonstrated a willingness to improve.

The Committee concluded:

“The imposition of Conditions is an appropriate Sanction where the Registrant’s impairment is of a significant nature, as in this case.”

The conditions include tight restrictions on handling controlled drugs, mandatory supervision, regular compliance reporting, and complete relinquishment of managerial control at the pharmacy.

Key Learning Points for Pharmacy Professionals

1. Legal and Ethical Obligations Must Be Upheld at All Times: Pharmacists are bound by law to ensure controlled and prescription-only medications are dispensed strictly in line with legal requirements. The scale of non-compliance in this case underscores the critical role of accurate record-keeping and ethical practice.
2. Controlled Drug Management Is a Core Responsibility: Failure to maintain accurate CDRs or selling Schedule 2 drugs without prescriptions is both a criminal and professional offence. Pharmacists must be vigilant in ensuring adherence to the Misuse of Drugs Regulations.
3. Professional Integrity and Trust Are Paramount: The breach of interim conditions—particularly where imposed to protect public safety—undermines trust in the profession. Pharmacy professionals must understand that failure to comply with regulatory orders can severely damage their professional standing.
4. Superintendent Pharmacists Hold Enhanced Accountability: Being in a leadership role intensifies the responsibility for oversight. This case demonstrates the consequences when that responsibility is misused or neglected.
5. Financial Motivations Can Never Justify Professional Misconduct: Even modest financial gains from unlawful supply compromise public safety and bring the profession into disrepute.
6. Patient Safety Must Remain the Foremost Priority: Dispensing high-risk medications without labels, dose instructions, or pharmacist advice poses unacceptable risks. The absence of patient counselling or monitoring magnifies the danger.
7. Insight, Remediation, and Compliance Influence Sanction Outcomes: Despite severe misconduct, demonstrable compliance, remorse, and remediation efforts over several years influenced the Committee’s decision to impose conditions rather than erase the registrant from the profession.

Pharmacists should reflect on this case as a potent reminder of the critical standards expected in the profession and the consequences when those standards are breached.

Original Case Document

The full determination transcript is available to logged in users.

Log in or Register for free to access.