Warning Issued to Locum Pharmacist for Methadone Dispensing Error and Drink Driving Conviction
Date of Decision: November 6, 2025
Registrant's Role: Pharmacist
Allegations:
- Attending shifts despite concerns raised by colleagues and patients
- Dispensing an incorrect prescription of methadone
- Conviction for driving with alcohol level above the legal limit
Outcome: Warning issued, valid for 12 months
GPhC Standards Breached:
- Standard 5 – Use professional judgement, including only practising when fit to do so
- Standard 8 – Reflect on concerns and take action to prevent them recurring
Case Summary
Allegations
This case concerns a locum pharmacist who was subject to a warning from the General Pharmaceutical Council (GPhC) following a series of professional and legal lapses. The first allegation relates to the registrant attending shifts at a Boots Pharmacy despite concerns raised by both colleagues and patients. These concerns ultimately resulted in the registrant being asked to leave the premises on more than one occasion.
The second allegation involves a dispensing error that occurred during one of these shifts. The registrant dispensed methadone—a controlled drug used in opioid substitution therapy—incorrectly to a patient. Fortunately, the error was identified by the patient and rectified before any harm occurred. However, this raised serious concerns about the registrant’s fitness to practise safely, particularly given the nature of the medication involved and the inherent risks of dosing errors in methadone dispensing.
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- Full allegations considered by the GPhC
- Panel findings and reasoning
- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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The original determination transcript is available to registered users.
- Download the official GPhC determination
- Full hearing transcript
- Detailed findings of fact
- Sanction reasoning
- Details of the pharmacy professionals involved
