Warning Issued for Dishonest Removal of Amitriptyline by Pharmacist
Date of Decision: October 27, 2025
Registrant's Role: Pharmacist
Allegations:
- Removed three boxes of Amitriptyline 10mg tablets from the pharmacy shelf without a valid prescription, payment, or employer permission.
- Provided a misleading initial explanation for possession of the medication.
- Admitted to taking the medication without authorisation.
- Acted dishonestly in contravention of professional standards.
Outcome: Warning issued, published on the GPhC register for 12 months.
GPhC Standards Breached:
- Standard 6 – Behave in a professional manner: are trustworthy and act with honesty and integrity
- Standard 8 – Speak up when they have concerns or when things go wrong: are open and honest when things go wrong
Case Summary
Allegations
The case revolves around a pharmacist who, on 12 August 2024, removed three boxes of 28 Amitriptyline 10mg tablets from the pharmacy shelf without obtaining a valid prescription, making payment, or securing permission from her employer. This conduct was identified during an internal investigation after the medication was discovered in the registrant’s vehicle. Initially, the registrant claimed the medication belonged to her mother. However, upon further inquiry, she admitted to having taken the medication from the pharmacy without appropriate authorisation.
The core allegation centres on dishonest conduct, particularly given the deceptive initial explanation and the unauthorised removal of a controlled medication from the pharmacy’s stock. Although not classified under controlled drugs legally, Amitriptyline is a tricyclic antidepressant often used for conditions such as neuropathic pain or depression and is not freely accessible without proper authorisation due to its potential toxicity in overdose and associated risks.
Findings
The GPhC’s Investigating Committee reviewed the circumstances and accepted that while the registrant was under personal strain at the time, the conduct still amounted to a breach of professional expectations. The registrant’s dishonesty, initially claiming the medication was her mother’s and then admitting to unauthorised removal, was a central finding of the case.
The panel took into account the registrant’s personal difficulties and the fact that she showed remorse and insight into her behaviour. However, the committee concluded that the actions demonstrated a clear failure to uphold expected standards of honesty and integrity. The handling of pharmacy medication, particularly without proper records or authorisation, was considered a serious breach regardless of any mitigating personal circumstances.
GPhC Determination on Impairment
The Committee determined that the registrant’s fitness to practise was not currently impaired, hence a full fitness to practise hearing or suspension was not deemed necessary. However, the actions were serious enough to warrant a formal warning.
In assessing impairment, the Committee noted that the conduct, although isolated, involved dishonesty—a behaviour considered fundamentally incompatible with the ethical expectations of healthcare professionals. Nevertheless, they acknowledged that this appeared to be an isolated incident, that the registrant had expressed clear remorse, and that there were no previous fitness to practise issues.
The Committee emphasised that integrity is a cornerstone of pharmacy practice and even a single incident of dishonesty must be addressed to maintain public trust.
Sanction
The Committee concluded that the appropriate outcome was a formal warning. This warning serves both a declarative and preventative function—highlighting the seriousness of the conduct and deterring any future lapses.
“On 12 August 2024, [the registrant] removed three boxes of 28 Amitriptyline 10mg tablets (the medication) from the shelf of the Pharmacy without a valid prescription, payment and or permission from her employer… [She] initially said that the medication was her mother’s but later admitted she took the medication from the pharmacy… Although [she] has expressed remorse and highlighted personal challenges that may have influenced her actions, such behaviour is unacceptable and contrary to the standards of professional conduct expected of a pharmacy professional.”
The Committee issued this warning to uphold public confidence in the profession and to reinforce that honesty and professional integrity are essential qualities for pharmacists. The warning will be published on the GPhC register for a period of 12 months.
Key Learning Points for Pharmacy Professionals
- Honesty and Integrity Are Non-Negotiable: Regardless of personal circumstances, dishonesty in the workplace—particularly in relation to the handling of medications—is a severe breach of professional standards.
- Importance of Transparency in Medication Handling: Removing stock from the pharmacy without documentation or authorisation is a breach of pharmacy protocol and can have serious regulatory consequences.
- Personal Struggles Are Not Excuses: While personal hardship can be mitigating, it does not excuse professional misconduct. Registrants are expected to seek appropriate support rather than compromise professional responsibilities.
- Insight and Remediation Matter: The registrant’s demonstration of remorse and acknowledgment of wrongdoing played a key role in the decision to issue a warning rather than escalate to a suspension or full hearing.
- Warnings Are Public and Significant: Even though this case did not result in a suspension, the warning will remain visible on the GPhC register for 12 months, serving as both a mark on the professional’s record and a message to the wider profession.
Pharmacists must remain vigilant in upholding standards, particularly concerning honesty, medication management, and professional integrity. Even isolated lapses can lead to public sanction and long-lasting professional consequences.
Original Case Document
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