Tesco Pharmacy Manager Suspended for Controlled Drug Dispensing Errors

Date of Decision: March 4, 2026

Registrant's Role: Pharmacist

Allegations:

On 29 December 2021, the registrant knowingly supplied Espranor to Patient A instead of Buprenorphine as prescribed.
On 23 March 2022, the registrant supplied Patient B with penicillin where Only 12 of the prescribed 40 tablets were supplied; This occurred without the patient’s knowledge; No attempt was made to contact the patient after the dispensing error was identified; and The error was not reported to the Regional Pharmacy Manager.
On 23 March 2022, the registrant supplied methadone to Patient C without a valid prescription.
The registrant did not engage in Tesco’s reflection process following dispensing errors. (Not proved)
The registrant did not provide written comments regarding dispensing errors as agreed with the Regional Pharmacy Manager. (Not proved)
Between 11 January 2022 and 30 March 2022, the registrant did not engage with a formal performance management process by failing to complete training required to provide Pharmacy First Patient Group Directions (PGDs). (Not proved)
On 17 March 2022, the registrant failed to follow safe custody regulations by leaving a Schedule 2 Controlled Drug (Targinact) outside the CD cabinet. (Not proved)

Outcome: Suspension from the register for 12 months, with an Interim Suspension Order imposed during the appeal period.

GPhC Standards Breached:

Standard 1 – Provide person-centred care
Standard 2 – Work in partnership with others
Standard 4 – Maintain, develop and use professional knowledge and skills
Standard 5 – Use professional judgement
Standard 8 – Speak up when there are concerns or when things go wrong
Standard 9 – Demonstrate leadership

Case Summary

Allegations

This case concerned a pharmacist who worked as a Pharmacy Manager at a community pharmacy within a large supermarket chain in Stirling between September 2021 and April 2022. The General Pharmaceutical Council (GPhC) received concerns following a high number of dispensing errors and near-miss incidents recorded in the pharmacy’s internal reporting systems.

The pharmacy maintained routine processes for documenting patient safety incidents, including Patient Incident Reports and Near Miss Logs. From October 2021 onwards, numerous incidents were recorded involving medicines with varying therapeutic uses and risk profiles. These included errors involving strength, dosage form, quantity, labelling, and occasionally the wrong medication being supplied. Examples included incorrect strengths of amoxicillin, incorrect contraceptive brands supplied (Lucette and Milinette), and incorrect quantities of medicines such as duloxetine and methadone.

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Full allegations considered by the GPhC
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Sanctions considered and imposed on the Pharmacist
Key professional learning points

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