A Spanish locum pharmacist has been suspended for six months for “deplorable” conduct with controlled drugs.

Manuel Jesus Romero Sanchez, registration number 2081422, removed a page from the controlled drugs register of a Lloydspharmacy in Bransholme, Hull, in December 2012, the General Pharmaceutical Council (GPhC) heard at a fitness-to-practise hearing on April 1. 

Mr Romero Sanchez also made an inappropriate emergency supply of morphine to a patient’s wife while working in a different branch. His knowledge of controlled drug regulations fell “seriously below” the expected levels of a competent pharmacist, the GPhC said.

The regulator noted that Mr Romero Sanchez, who had since returned to Spain, later claimed that he had not received adequate training from the agency that brought him to work as a pharmacist in the UK. He had also demonstrated “some insight” into his actions, it said.

‘Unaware of standard practice’

In October 2012, Mr Romero Sanchez made an emergency supply of morphine to a terminally ill patient's wife. The pharmacy’s records showed that the woman was “very persuasive” and Mr Romero Sanchez was “unaware that it was not standard practice to issue a controlled drug as an emergency supply”, the GPhC heard.

At the fitness-to-practise hearing, the GPhC saw the controlled drugs register from the Lloydspharmacy in Bransholme, which had a page missing. The “remnants of the page were clearly visible in the spine of the register”, said the GPhC, which noted that there had been "no attempt to cover up" its removal. 

Mr Romero Sanchez was the responsible pharmacist on the last working day before the missing page was discovered, the GPhC said. Although he denied the accusation, the GPhC concluded it was "more likely" that he was responsible, because other pharmacy staff working that day would have known the "seriousness of such an act as well as the ease with which it would be detected".

Although the removal of the page was a criminal act, the GPhC was not convinced that Mr Romero Sanchez had acted dishonestly because it could not rule out that his "lack of knowledge of regulations extended to the inviolability of a controlled drugs register".
 

More dispensing errors

Mr Romero Sanchez made seven other dispensing errors while working as the responsible pharmacist across six different branches between July and October 2012, it heard. These included harming a child by providing twice the prescribed strength of constipation medicine Movicol while working in a Lloydspharmacy in Wakefield.

On the same day, Mr Romero Sanchez supplied another patient with co-careldopa instead of co-beneldopa, and went on to make five further dispensing errors over the next three months in Lloydspharmacy branches in Castleford, Pontefract, Hull, Normanton and Cleckheaton, the GPhC heard.
 

'Lack of relevant training'

The GPhC accepted Mr Romero Sanchez had no history of disciplinary action and had admitted to some of his actions at an early stage in Lloydspharmacy’s internal investigations. He had shown “some insight” into his inappropriate emergency supply of morphine, but this “stopped short of full and unequivocal insight into the seriousness of the conduct”, the GPHC said.

He had also appeared to express regret at the harm his dispensing error had caused to a child, in an email from 2014, it said. In the same email, Mr Romero Sanchez blamed the “bad training” he had received by the agency that had employed him in the UK. The GPhC said it had no information about what was included in this training.

It stressed that Mr Romero Sanchez's misconduct had been repeated over a “significant period” and had caused “actual harm” to a patient. While dispensing errors were an “occupational hazard in pharmacy”, Mr Romero Sanchez “did not seem to appreciate the seriousness” of his emergency supply or removing the page from the controlled drugs register.

It ruled to suspend him from the register for six months, which it said would allow him time to engage in training and professional development.
 

Read the full determination here.

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