Former pharmacy manager Nichola Mary Johnstone, registration number 2038420, was handed a 12-month suspension by the General Pharmaceutical Council (GPhC) after it found she made “serious” dispensing errors while working at a Tesco pharmacy.
At hearings in February and March, the GPhC’s fitness to practise committee heard that Johnstone failed to conduct “sufficiently careful clinical and accuracy checks” in relation to a series of errors and near-misses.
According to the hearing document, she also “knowingly supplied Espranor” to a patient “instead of Buprenorphine”, and supplied another patient with “only 12” of the 40 penicillin tablets they were prescribed.
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One patient was also supplied methadone “in the absence of a valid prescription”, it added.
Any mitigating factors identified by the committee were redacted in the hearing document.
And the GPhC said there was “no early admission of the facts” by Johnstone.
Series of incidents
The committee noted that Johnstone “was an experienced pharmacist of 19 years” before her employment at a Tesco pharmacy in Stirling, Scotland, and had also been a superintendent pharmacist in her previous role.
It heard that between September 2021 and April 2022 - while Johnstone was working as a pharmacy manager at the Tesco store - a number of dispensing errors and near-miss incidents “involving a range of medicines” were recorded on the pharmacy system.
The incidents included “errors relating to strength, form, quantity, labelling and, in some cases, the wrong item being supplied,” the GPhC said.
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Johnstone was “involved in a high number of these incidents in some capacity,” it added, and they “were reviewed by management”.
In early 2022, Johnstone met with her regional manager a number of times for informal meetings to “discuss performance concerns”, and an “action plan meeting” was held on March 8, 2022.
The regulator said these meetings “addressed issues relating to dispensing accuracy, reflection processes and completion of required training”.
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In February of the same year, Tesco “initiated a high incident review due to the number of reported incidents within a 26-week period”, and a report summarising the incidents and the “steps taken locally to address them” was produced.
Two further incidents were recorded in March 2022 - one involving “patient B”, who was supplied with fewer tablets than prescribed, and another involving “patient C”, who was given methadone “in circumstances where the validity of the prescription later became an issue”.
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The incidents “were discussed at an investigatory meeting” attended by Johnstone and management representatives later that month, the GPhC said.
It added that Johnstone was “suspended from her role pending further investigation” on April 1, 2022, and she “resigned from her employment” on April 21.
On April 4, 2022, the deputy superintendent pharmacist for Tesco referred concerns about the Johnstone’s fitness to practise to the GPhC.
“No apology”
The GPhC noted that Johnstone has “provided no evidence of apology or remorse” for her conduct since resigning from her role at Tesco, and has made “no efforts to prevent similar things happening again” or “put problems right”.
It said the errors had “occurred over a period of months” and were “compounded by the fact” that Johnstone “continued making errors of a type and similar nature from September 2021 to April 2022”.
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“The risk to patients would have been obvious to any pharmacist,” it added, and the errors “were serious, especially in relation to controlled drugs”.
The regulator highlighted that Johnstone “has not remediated the circumstances by demonstrating regret” or “taking steps to prevent a repetition, for example through reflective practice, CPD or other training”.
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It added that she has not provided the committee with any information, other than to say that “she wishes to ‘tender her resignation from the GPhC with immediate effect’” in a letter dated February 16, 2026.
There is also “no evidence” that Johnstone “has worked safely and professionally in the same or similar role since the events causing concern”, it said, nor any evidence of her “keeping up to date” with her area of practice.
“Not remediable”
The GPhC found that Johnstone’s conduct was “not remediable” and that “there is a risk of repetition”.
It said the “frequency of serious errors which could have compromised patient safety and even proved dangerous”, as well as the “lack of any engagement throughout the fitness to practise process”, presents “a considerable risk”.
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The committee decided that Johnstone would be suspended for 12 months.
The sanction “would adequately reflect the serious nature” of her misconduct, “would meet the overarching objective of public protection” and “would be in the public interest”, it said.
Read the determination in full here.
