Warning Issued to Superintendent Pharmacist for Unsafe Dispensing of Anticoagulant Medication

Date of Decision: July 3, 2025

Registrant's Role: Pharmacist

Allegations:

Failure to implement appropriate Standard Operating Procedures (SOPs) and systems for the safe dispensing of high-risk medications, including anticoagulants.
Dispensing a different anticoagulant medication without adequate safety checks, despite prior supply of a similar medication.

Outcome: Warning issued

GPhC Standards Breached:

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

Case Summary

Allegations

The case examined by the General Pharmaceutical Council (GPhC) on 3 July 2025 revolved around the professional conduct of the registrant, a Superintendent Pharmacist (SI) overseeing a retail pharmacy in Weybridge. The allegations concerned serious lapses in safe dispensing practices, specifically relating to the handling and supply of high-risk medicines such as anticoagulants. As SI, the registrant was directly responsible for establishing and maintaining pharmacy systems and Standard Operating Procedures (SOPs) to ensure the safety and accuracy of medication supply.

The GPhC Investigating Committee was presented with evidence that the registrant had failed to implement adequate SOPs and pharmacy systems aimed at safely dispensing high-risk medications. The concern intensified following a specific incident on 12 October 2020, where the registrant dispensed a different anticoagulant to a patient who had received another type of anticoagulant only ten days prior. This occurred without conducting thorough checks to verify the appropriateness and safety of administering two distinct anticoagulants in close succession, a practice that could lead to serious patient harm due to the bleeding risks associated with such medications.

Findings

The panel determined that the registrant’s failure to implement comprehensive SOPs for handling high-risk medications represented a systemic weakness in the pharmacy’s operation. As a Superintendent Pharmacist, the registrant holds the ultimate responsibility for ensuring robust governance and clinical safety. By not safeguarding the dispensing process—especially for anticoagulants which carry well-documented bleeding risks—the registrant neglected fundamental clinical responsibilities.

Furthermore, the clinical checking failure on 12 October 2020 underscored a lapse in professional diligence. Anticoagulants such as warfarin, apixaban, rivaroxaban, and others require careful monitoring due to their potential for adverse drug interactions and cumulative anticoagulant effects. The registrant’s failure to verify the patient’s prior medication history or consult prescribing records before dispensing a different anticoagulant placed the patient at undue risk.

GPhC Determination on Impairment

Although the registrant’s conduct was not escalated to a fitness to practise hearing, the Investigating Committee concluded that the breaches did raise serious concerns about the registrant’s adherence to professional standards. The Committee found that the registrant had breached the following GPhC standards for pharmacy professionals (2017):

Standard 1: Failure to provide person-centred care by not considering the implications of medication changes on the patient.
Standard 2: Not working collaboratively with other healthcare providers to ensure continuity and safety in care.
Standard 5: Inadequate use of professional judgement in clinical decision-making.
Standard 9: Lack of demonstrable leadership in establishing effective pharmacy systems.

The panel expressed concern that these failures, although not resulting in proven patient harm in this instance, had the potential to cause serious adverse outcomes. They also noted the reputational damage such oversights could inflict on the pharmacy profession.

Sanction

The outcome determined by the GPhC was a formal warning. The Committee emphasized that while this was not a suspension or removal from the register, it constituted a significant regulatory response to underscore the gravity of the failings.

“[The registrant] is warned that, in future, he must at all times have in place appropriate systems to ensure the safe and effective supply of medication and must follow these when conducting clinical checks. Any repetition of the failings identified is likely to lead to further regulatory action.”

The warning will be published and remain on the GPhC website for a period of 12 months, serving both as a record of the incident and a deterrent for similar conduct.

Key Learning Points for Pharmacy Professionals

Importance of Robust SOPs: Pharmacy professionals, particularly in leadership roles, must ensure SOPs are comprehensive, up to date, and rigorously followed, especially concerning high-risk medicines like anticoagulants.
Clinical Vigilance in Medication Changes: Dispensing alternative medications—particularly anticoagulants—requires careful consideration of the patient’s medication history and clinical status. Failing to do so can result in therapeutic duplications or drug interactions.
Leadership Responsibilities: Those in Superintendent roles are accountable for creating a culture of safety and compliance. Leadership includes anticipating potential risks and proactively managing them through system design.
Person-Centred and Collaborative Care: Ensuring the safety of patients extends beyond the individual act of dispensing—it involves coordination with other healthcare professionals and considering the patient’s treatment trajectory.
Regulatory Implications: Even if harm does not occur, breaches in professional standards can result in formal warnings that affect professional reputation and signal heightened scrutiny from the regulator.

This case reinforces the GPhC’s expectation that pharmacy professionals uphold the highest standards of care, clinical judgment, and leadership, particularly when managing medications that present heightened safety concerns.

Original Case Document

The full determination transcript is available to logged in users.