Mystery of the missing meds

tribunal hearing legal case

A Tribunal has heard of a pharmacist’s “flagrant” breaches of obligation including dispensing drugs of addiction on forged scripts, being unable to account for thousands of Endone and Duromine tablets, and smoking an e-cigarette in the dispensary

A Sydney pharmacist has been found to have engaged in misconduct involving the dispensing, storage and dispersal of drugs of addiction and other related substances.

The Civil and Administrative Tribunal NSW heard an amended complaint from the Health Care Complaints Commission alleging that a Sydney pharmacist was guilty of unsatisfactory professional conduct and professional misconduct in his practice as a member of the profession.

The man was first registered to practise as a pharmacist in November 2014, and from April 2018 on, was working at two south-west Sydney discount pharmacies.

At the first pharmacy, he was the sole pharmacist and pharmacist in charge during the time of the behaviour in question.

The pharmacies were owned by a corporate structure with two principals, one of who alerted regulators to the pharmacist’s activities, alleging that forged scripts for S8s had been found at both stores.

He also said scripts for an S4D drug had been found at the first pharmacy, that significant quantities of both types of drugs had been stolen from both pharmacies, and that the S8 drug registers had not been kept properly at either store.

In February 2019, the Pharmaceutical Regulatory Unit inspected the premises of the first store, followed by another inspection that April.

At the first pharmacy, the pharmacist was found to have failed to account for a significant amount of drugs.

These included 2,760 tablets of Endone 5mg; 168 tablets of OxyContin 40mg; 450 tablets of Alprazolam 2mg; 28 tablets of Targin 5/2.5mg and another 28 of Targin 15/7.5mg; 2,640 tablets of Duromine 30mg and 2,400 of Duromine 40mg.

These quantities were derived using wholesaler and dispensing records as well as the opening and closing balances of these drugs in the Dangerous Drugs registers.

The pharmacist did not participate in the proceedings, but during the course of his Section 150 hearing he said that, “he frequently received stock intended for other pharmacies owned by the same proprietors and was required by them to transfer this stock to those pharmacies”.

“He said that he sometimes drove the stock after work in his own vehicle to take it to the other pharmacies or to the homes of the proprietors,” the Tribunal noted.

The proprietors said this was not the case – especially for these sorts of drugs.

CCTV footage taken on dates in January 2019 was compared with invoices and receipts.

“When all of this information is considered, it establishes that certain items which are capable of being identified are removed from packages delivered to the pharmacy and placed in black bags which in turn are taken away from the pharmacy by the respondent” the Tribunal observed.

“We add for completeness that there are no pharmacy records of these drugs having been dispensed by the respondent, nor are there any records of any prescriptions held to corroborate their dispensing.”

This particular of the complaint – which the Tribunal said it accepted – alleged that the pharmacist had removed a number of drugs from the premises.

On one date in January these included up to eight bottles of Alprazolam 2mg, for a total of up to 400 tablets; up to 12 packs of Endone 5mg, for a total of 240 tablets; 12 packs of Duromine, for a total of 360 tablets; and one bottle of Loxicom 1.5mg/ml 100ml oral suspension.

A week later the same thing happened to up to another eight packs of Endone 5mg and up to 12 of Duromine.


Forged scripts

The complaints against the pharmacist included that between May and August 2018, he inappropriately dispensed 120 tablets of Endone 5mg when presented with a forged script written using a prescription pad from a prescriber identified at the hearing as Medical Practitioner A.

He did this for 23 different patients, each of whom received quantities of 120 Endone 5mg on the private scripts, the Tribunal observed.

“In each case the prescriptions against which these drugs were dispensed was forged,” it noted.

At the s150 hearing he had claimed to have attempted to contact the doctor about the script on one occasion, but was unable to do so, instead speaking to a secretary who confirmed the recipient was a patient.

He had also said during the s150 hearing that he was familiar with these patients, having seen them when they came in for OTC medicines.

The PRU had also been unable to locate the duplicate of the original of seven scripts.

Similar treatment was given to OxyContin: one particular of the complaints alleged that the pharmacist had inappropriately dispensed 56 x 40mg OxyContin to four different patients between August and September 2018, again on forged scripts. On one occasion, there was no corresponding original prescription duplicate to be found.

In January 2013, the pharmacist dispensed 50 tablets of Alprazolam 2mg on a forged script which did not contain written directions for use; he also dispensed 100 tablets of the same medicine in October 2018, but again there was no original duplicate.

The Tribunal also heard that in around April 2018, he also inappropriately dispensed Physeptone 10mg without properly recording it in the DD register and on a script which did not have adequate instructions for use, and where the quantity was not expressed in both words and figures.

In July 2018, the pharmacist also dispensed Duromine 30mg on a forged script with five repeats, dispensing 180 tablets in total, all at once. Other patients also received inappropriately dispensed Duromine.

Again, the script pad was from Medical Practitioner A, who confirmed that they were forgeries.

A pharmacist expert told the Tribunal that, “The usual dose of Duromine 30mg is one capsule daily, so that 30 capsules would be sufficient for one month. However, the respondent dispensed a total of 180 tablets to each patient”.

She noted that “the Australian Medicines Handbook states that short-term treatment is recommended for this drug which may be up to three months”.

“On this basis she said that the recognised therapeutic standard would be to dispense one box of medication at a time,” the Tribunal said.

Again on a forged script, in June 2018 the pharmacist inappropriately dispensed 12 Primoteston 250mg/1ml depot syringes, and failed to endorse the word “cancelled” on the script.

Dispensing records show that three patients received four syringes each on that day.

“In total, the respondent dispensed 12 syringes on that day to each of these three patients,” the Tribunal noted.

The pharmacist expert gave evidence that, “the usual therapeutic dose of Primoteston is one syringe every two to three weeks. Accordingly, a supply of 12 syringes would be sufficient for 24 to 36 weeks.”

At the second pharmacy, the practitioner was found to have inappropriately dispensed Endone 5mg and OxyContin 40mg, on a computer-generated forged script.

Nine scripts were involved, all of which were identified as fakes by the prescriber whose name was used.

The pharmacist was also found to have failed to undertake accurate stock checks for S8s at the first pharmacy and, between May 2018 and February 2019, failed to make entries in the drug register regarding the receipt of S8 drugs of addiction on the day they were received, or their supply on the day they were supplied (namely Endone 5mg, OxyContin 40mg and Alprazolam 2mg)

He also made false entries in the DD register on five occasions.

The PRU officers also obtained CCTV footage from the pharmacy, which provided some interesting material.

This showed that on a date in January 2019 while he was the only pharmacist in the pharmacy, the pharmacist left the premises through the front door… clearly leaving a safe, identified as the pharmacy drug safe, open.

The same footage also showed him clearly smoking an e-cigarette in the dispensing area.

The CCTV footage from January 2019 also showed the pharmacist handing over two takeaway methadone bottles which were unlabelled to patients.

In outlining why it had found the pharmacist guilty of professional misconduct, the Tribunal pointed out that if the missing drugs “were dispersed in the general community without close medical supervision, they would create a significant risk to the health and safety of the public”.

“We assess the conduct of the respondent as we have described it as constituting a flagrant breach of his legal, professional and ethical obligations as a practising pharmacist,” it said.

“His conduct is clearly incompatible with the practice of his profession at a standard which can reasonably be expected by the public. This renders him unfit to practise as a pharmacist and justifies the cancellation of his registration.”

The pharmacist was also reprimanded and may not apply for review of the cancellation for five years.

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  1. Sean

    C’mon this pharmacist should NEVER practice again in pharmacy!!!!

  2. Philip Smith

    So, would this have happened if the owners showed up more often and checked the safe records?
    While not their fault, owners do have some responsibility, not just employ someone and forget about it.

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