Owner ‘abdicated’ professional obligations, Tribunal finds


tribunal hearing legal case

A pharmacy owner has been found guilty of professional misconduct after more than 10,000 Endone tablets went missing due to an employee’s actions

The pharmacist is the sole owner of one western suburban Sydney pharmacy, as well as a partner in two pharmacies near Newcastle. He also was previously the owner of a second eastern Sydney pharmacy, which he sold in March 2018.

In March 2015, the NSW Ministry of Health Pharmaceutical Services Unit was sent a statutory declaration by the owner, reporting the loss of an S8 drug register from the eastern Sydney suburban pharmacy.

In April 2015, a PSU senior pharmaceutical officer attended the pharmacy in question, as well as the pharmacy in the western suburbs.

She performed an inventory count of all drugs of addiction at the eastern pharmacy, and obtained records including the drug register from the western pharmacy, as well as the S8 prescriptions for both.

She also obtained records from the wholesaler of purchases made by both pharmacies.

After performing a quantitative analysis of data regarding the acquisition and supply of Endone tablets at the western suburbs pharmacy between May 2014 and April 2015, the PSU officer found 785 Endone tablets (39 proprietary packs) were unaccounted for.

Meanwhile another 9,260 Endone tablets – 463 proprietary packs – were unaccounted for at the eastern pharmacy between June 2014 and April 2015.

Another pharmacist was employed as the pharmacist in charge at the eastern pharmacy at the time, as well as a locum pharmacist at the western premises on Sundays.

The Tribunal noted that there was no suggestion that the pharmacy owner had misappropriated the missing Endone, and that the employee had also been the subject of disciplinary hearings.

It noted that the hearing concerned his conduct as a proprietor and the steps he should have taken regarding the missing S8s, as well as his role in supervising his staff in their dispensing of compliant prescriptions, record keeping, and failing to report written confirmation of prescriptions from OTP prescribers to NSW Ministry of Health.

It also observed that the owner’s background included previous investigations, including one in which the owner admitted to have handled and supplied pseudoephedrine tablets in a manner contravening the then Pharmacy Board’s Guidelines; and another regarding the supply of methadone and buprenorphine from one of the northern pharmacies. In the latter case his partner provided documentation and authorities took neither case further.

When the pharmacy owner contacted the PSU in March 2015 about his suspicions regarding the employee’s misappropriation of S8 drugs, he was interviewed and a number of instances of apparent non-compliance with the provisions of the NSW Poisons and Therapeutic Goods legislation were identified.

The PSU officer noted alterations, obliterations and cancellations made to the register by the pharmacists at the stores, and that there did not appear to have been a complete March 2015 stock check.

She discovered that repeat prescriptions for Schedule 4 Appendix B substances had been issued by pharmacists at the western premises where no interval of repeat was specified by the prescriber; and that pharmacists at that store dispensed a number of S8 scripts with apparent alterations made by a person other than the authorised practitioner by whom it was issued.

Where the prescription was computer generated, there was no complete confirmation of the prescription in the prescriber’s own handwriting. The quantity of drug was not written in both words and figures.

In September 2015 the PSU inspected the OTP dosing at the three pharmacies at which the owner held an interest, namely the western and two northern pharmacies.

Eventually the owner’s registration was suspended.

In late November 2019, he faced a hearing investigating whether he had engaged in unsatisfactory professional conduct, and/or professional misconduct.

The hearing noted that in January 2015, he had failed to immediately notify authorities when the missing Endone issue was uncovered in the eastern pharmacy.

He then in February inappropriately requested a pharmacist in his employ not to notify authorities.

In March 2015, he was made aware of a discrepancy of 600 Endone tablets at the western pharmacy and inappropriately requests that the matter not be reported; he also declined a request by an employed pharmacist that an Endone stocktake be conducted.

The hearing noted that between April and September 2015 he failed to ensure the drug register kept at the western pharmacy was properly kept by pharmacists in his employ. In September of that year he also failed to ensure that two S8 drug safes were affixed to that premises.

He also failed to identify and report the loss of 10 Suboxone 2mg films at the western premises in circumstances where an audit on 22 September 2015 showed that 10 Suboxone 2mg films were not accounted for and the Director General of the NSW Ministry of Health was not immediately notified of any loss.

The owner denied that this conduct amounted to either unsatisfactory professional conduct or professional misconduct.

Instead, he said he was unaware in January 2015 that the Endone had gone missing from the eastern pharmacy, and that he had not asked anybody not to report this.

He said that upon discovering the discrepancy he instigated a stocktake, adding that he felt that he employed competent pharmacists in charge who were aware of their obligations, and that he attended all his pharmacies to oversee and confer with the staff.

The hearing found that it was not proven that the owner knew the Endone had gone missing as at January 2015, or that he asked a staff member not to report this.

He said that upon discovering the discrepancy he instigated a stocktake.

He said he felt that he employed competent pharmacists in charge who were aware of their obligations, and that he attended all his pharmacies to oversee and confer with the staff.

The hearing found that it was not proven that the owner knew the Endone had gone missing as at January 2015, or that he asked a staff member not to report this.

However the hearing found that the allegation that the owner had failed to maintain an accurate inventory of the S8 drugs at the western premises was proven.

The owner acknowledged that he did not ensure that the Drug Register at this pharmacy was kept properly by the pharmacists he employed. The hearing found this complaint proven.

“A pharmacist who is a proprietor must maintain and be able to demonstrate an awareness of the manner in which their pharmacy business is being conducted and, where necessary, intervene to ensure that the practice of pharmacy is conducted in accordance with applicable laws, standards and guidelines,” the Tribunal noted.

“A failure to be attentive as to whether statutory requirements, standards and guidelines are being adhered to diminishes this protective structure.

“This was not a case of a one off contravention of the requirements of the PTGR by one pharmacist or at one pharmacy but of multiple contraventions.”

It noted that in its view, the owner had “abdicated his professional obligations as a proprietor” and found him guilty of professional misconduct.

The matter will now be listed for directions and a date fixed for a hearing to complete the matter.

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