I read with interest C+D’s reporting on a fitness-to-practise (FtP) case in which a pharmacist was suspended this September, because he “caused or allowed” Oramorph and oxycodone hydrochloride to be substituted for “water or another liquid including water” back in 2018.
The case raises a number of questions but, before I get to them, I want to tell you about another.
“Quite staggering”
Mr R, a pharmacist, was convicted of stealing from his employer between 1978 and 1980. He was sentenced to 240 hours’ community service in 1980. The pharmacy regulator knew about the conviction when he was sentenced, but only opened an inquiry into Mr R in January 1983.
A hearing took place in April 1984, some three and a half years after the conviction and around four years after the last theft. During that time, Mr R had done all he could to rebuild his life, including starting a new pharmacy of his own.
The committee contemplated whether the passage of time in this case could justify not removing Mr R from the register. It decided “no”, and struck him off.
Read more: GPhC fails FtP timeliness standard for eighth year in a row
I was a young solicitor, and Mr R turned up on my doorstep, asking me to lodge an appeal to the High Court on his behalf.
Mr Justice Taylor described the four-year delay in bringing the case as “quite staggering”.
He said: “I am appalled at that chronology. It seems to me that to delay for that length of time, without any good excuse, is to deny justice to the appellant.”
Read more: Exclusive: PSA appealed two GPhC decisions on sexual misconduct
The judge went on to say that if the committee had known that the “lamentable” delay was the fault of the pharmacy regulator, the committee’s decision “would have come down on the other side of the line”.
Mr R’s striking off was replaced with a reprimand. How times have changed.
It is worth looking at two recent reports on the General Pharmaceutical Council’s (GPhC) handling of FtP cases.
Performance
In its annual report published last month, the GPhC announced that its median timeline for closing FtP cases “remains very high at just under three years”.
The Professional Standards Authority (PSA), which oversees all UK healthcare regulators, recently published its annual review of the GPhC’s performance and found that it had 142 open FtP cases that were more than two years old. In 65% of cases audited by the PSA, it identified examples of “avoidable or unexplained delay” in the triage and investigatory stages.
In the recent case reported by C+D, the pharmacist involved was given a four-month suspension in 2026 for misconduct in 2018. Unfortunately, the FtP committee’s decision does not provide us with a chronology.
Read more: From a lawyer: Can regulators enforce weight loss drug laws?
We do know that there was a police investigation and that it closed in September 2018. We do not know when the GPhC became aware of the case.
We do know one other thing, about the passage of time. The GPhC’s own rules say that FtP cases must not proceed if “more than five years have elapsed since the most recent events referred to in the allegation, unless the registrar considers that it is necessary for the protection of the public, or otherwise in the public interest”.
This suggests that old cases should not normally be pursued unless there is a particular need for protection. We can assume, therefore, that the registrar considered there were specific reasons for this case to proceed. We do not know what those reasons were.
Read more: Exclusive: GPhC takes first enforcement action over POM ads
The hearing concluded on September 17. The committee found that there was no dishonesty (which may surprise some who read the decision) but that the pharmacist was guilty of misconduct which was “serious” and had the “potential to bring the profession into disrepute”.
The committee then had to decide whether the pharmacist’s fitness to practise was impaired.
According to GPhC guidance on good decision-making, a pharmacy professional is fit to practise “when they have the skills, knowledge, character, behaviour and health needed to work as a pharmacist safely and effectively”.
“In practical terms, this means maintaining appropriate standards of competence, demonstrating good character, and also keeping to the principles of good practice set out in our various standards, guidance and advice,” it says.
Mitigating factor
You might ask how, if the pharmacist’s fitness to practise was impaired in 2026, he had been allowed to continue practising for eight years since the complaint was made.
Without a chronology, that is another question that is not easy to answer.
What the FtP committee said was: “A finding of current impairment is necessary to mark the seriousness of the registrant’s misconduct and thereby maintain public confidence and promote professional standards by making clear to other professionals what is expected and deterring other professionals from failing to meet standards.”
Read more: RCPharm: Performers list could offer alternative to FtP referrals
The committee then went on to decide what sanction to impose. This is where the time factor came back into play. The committee did not say that it was unfair for the pharmacist to have had the case hanging over his head for so many years.
However, the committee did consider it was a mitigating factor that it “has been eight years since the time of the incidents and he practised safely and effectively throughout”.
Read more: ‘Significant rise’: GPhC received almost 10,000 concerns this year
The committee decided that striking the pharmacist off would be disproportionate. Both the pharmacist’s lawyer and the GPhC’s lawyer suggested that appropriate sanction should be a period of suspension, and the committee agreed.
Since it is a mitigating factor to practise “safely and effectively” for a long period before an FtP hearing takes place, a lot of pharmacy professionals are going to benefit from this mitigation until the GPhC can reduce the persistent delays in its processing of FtP cases.
David Reissner is Chair of the Pharmacy Law & Ethics Association