Matthew Cook, registration number 2232309, has been removed from the General Pharmaceutical Council (GPhC) register after repeatedly giving the same patient more methadone than prescribed and failing to record the amounts dispensed.
At hearings between October 5 and 12, the GPhC’s fitness-to-practise committee found the pharmacist’s actions were “deliberate” and done with “a reckless disregard to the harm that they could cause”.
According to the hearing document, Cook also dispensed an incorrect drug to a patient, put medication for one patient in another patient’s bag and “attended work whilst unfit to do so”.
“I trusted him”
The GPhC said that on one or more occasions between January and March 2025, when Cook was working as a locum pharmacist at an unnamed pharmacy, he dispensed “approximately 65 ml more” than the prescribed dose of methadone for a patient referred to as patient A.
Patient A said in her witness statement that one day at the pharmacy, Cook gave her an extra bottle of methadone and “winked” at her.
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“I didn’t really know what to do, so I decided to just take the extra methadone home and use it,” she added.
Patient A said that after this, Cook would “often” give her extra methadone when visiting the pharmacy, even if she had already taken her home dose that day.
“I am sure he knew I had already had my home dose as I sometimes asked him if it was safe, and he told me it would be,” she said. “I trusted him as he was a pharmacist.”
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The committee decided Cook’s actions were “deliberate” because he would have known patient A’s medical history, he had dispensed to her before and he “must have been aware of patient A’s vulnerabilities”.
Patient A also wrote in her statement that she “suffered from fits” and was “really ill”, and “knew I had to stop taking the extra medication Matthew was giving me”.
“When I started thinking about that I then became concerned about what Matthew was doing,” she said. “I wasn’t worried about myself but thought he might give extra methadone to someone else, and they could get badly hurt or even die.”
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Patient A said she went to the pharmacy when Cook was not there and told the pharmacy staff that Cook had given her extra methadone, and they “started to write things down”.
In light of the evidence provided, the committee found that Cook’s actions “did amount to a reckless disregard to the harm that they could cause”.
According to evidence from a witness from the pharmacy, referred to as GG, Cook had failed to accurately record the amounts of methadone he dispensed to patient A on “one or more occasions”.
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GG said they had corrected the controlled drugs register by adding in additional entries for doses dispensed to patient A on January 29 and 30.
“These were doses that Matthew had told me he had dispensed but had been missed off the system,” they added.
“Erratic” and “unprofessional”
Cook was not at the hearing, but admitted to other allegations over email after the regulatory proceedings had begun.
He admitted to dispensing 10mg of amlodipine to patient C instead of the prescribed amitriptyline 10mg, as well as putting one patient’s medication in the bag for another, different patient.
Cook also admitted to five allegations concerning working “whilst unfit to do so” and behaving in an “erratic” and “unprofessional” manner.
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This included calling “one or more colleagues a ‘rich bitch’” and “a ‘snitch’”, and using words to the effect that he would “give them a piece of [his] mind”.
On “one or more unknown dates” Cook fell asleep during work, had once been “unsteady” on his feet and once had “slurred speech and jittery movements”.
The pharmacist also admitted to saying to a colleague, “shall we crush them up and snort them off the worktop?”, or words to that effect, in reference to paracetamol.
Struck off
The committee said it was “unable to identify any mitigating factors” in the case and there was “no evidence of any remorse or insight” demonstrated by Cook.
It noted the “actual harm caused to patient A and patient C” by Cook, and said patient A was “particularly vulnerable which aggravated the harm caused”.
And it stressed that Cook’s behaviour towards his colleagues was “unprofessional and reprehensible”, and that his misconduct was “numerous and repeated over the material time”.
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The regulator also pointed out that he was “in a position of trust” and had “abused that trust”.
It found that he had displayed a “lack of engagement with the regulatory disciplinary process”, including when he sought an adjournment but failed to attend.
The committee said that Cook’s breaches of five of its standards were “serious” and that a suspension “would not be sufficient to protect the public”.
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It added that it was “satisfied” that Cook’s misconduct and lack of insight and remediation had “amounted to conduct that was incompatible with continued registration”.
The committee concluded that removal from the register was the “appropriate and proportionate sanction”.
Read the determination in full here.
