Reprimand over missing S8s

A former pharmacist has been disqualified from applying for registration to practise the profession for 12 months, after he “put his head in the sand” over oxycodone discrepancies

The Melbourne pharmacist, a former councillor with the PSA’s Victorian branch, had been registered since 1966, and owned a pharmacy in a Melbourne suburb.

AHPRA had received a notification from the Drugs and Poisons Regulation Unit of the Department of Health and Human Services, which had conducted an investigation into an apparent discrepancy between the number of oxycodone tablets purchased and the number of oxycodone tablets dispensed by the pharmacist between 2013 and 2015.

The investigation compared the number of Oxycontin tablets supplied by Sigma to the pharmacist to the number of tablets dispensed and on hand, for the period January 2013 to Mach 2015.

This comparison showed a number of missing tablets: 454 Oxycontin 80mg tablets, 249 Oxycontin 40mg tablets, 112 Oxycontin 15mg tablets and 51 Oxycontin 10mg tablets, a total of 866 tablets unaccounted for.

The investigation did note that these quantities were likely to be offset by quantities of Oxycontin where the dispensing records exceeded the wholesaler records.

“So some discrepancies were likely to have occurred as a result of dispensing or recording errors as to the strength of the medication actually supplied,” the Tribunal noted.

“When these discrepancies were taken into account 812 Oxycontin were unaccounted for, the bulk of which were 40mg and 80mg tablets.”

The S8 register at the pharmacy was examined, and found to record two entries for the same script on nine occasions.

The balance in the register was amended or adjusted without justification on 23 occasions, and it was not updated to reflect the number of tablets supplied by Sigma on 12 occasions.

Between 2 March 2015 and 20 April 2015, the pharmacist dispensed prescriptions and failed to use the pharmacy barcode scanner 45% of the time.

The pharmacist, at that time, declined an interview and offered no explanation for the noted discrepancies.

He was initially charged with 41 offences under the regulations, but in November 2016 he pleaded guilty to two of these charges as well as six new charges, which rolled up the offences contained in the remaining charges. The other charges were withdrawn/struck out.

The pharmacist pleaded guilty to:

  • Two counts of supplying a Schedule 8 poison (oxycodone) without a prescription.
  • Two counts of failing to notify the Secretary of discrepancies in his records pertaining to a Schedule 8 poison (oxycodone) (12 occasions).
  • Two counts of making false or misleading entries in his records pertaining to a Schedule 8 poisons (oxycodone) (9 entries).
  • Two counts of failing to record a transaction involving a Schedule 8 poison in his records (oxycodone) (involving 10 failures).

He was found guilty without conviction of eight offences under the Drugs Poisons & Controlled Substances Regulations 2006 (Vic) regarding the supply and record-keeping of oxycodone.

He was sentenced to an aggregate fine of $16,000 plus ordered to pay $10,000 in legal costs.

In September 2018, the Pharmacy Board referred four allegations – these pertaining to his having been found guilty without conviction of the eight offences – to the Victorian Civil and Administrative Tribunal.

By this time, the Board and the pharmacist had prepared an Agreed Statement of Facts relating to the allegations, the characterisation of the conduct, and the determinations.

The Tribunal heard that on 23 December 2016, due to immediate action proposed by the Board when the offences came to light, he undertook not to practise as a pharmacist until he notified the Board in writing of his retirement from the profession.

He applied to have his registration cancelled, and on 23 March 2019 he became unregistered.

The pharmacist did not give evidence to the Tribunal hearing, but had made two statements to AHPRA in the course of the investigation.

The first of these, in 2016, said that when he made adjustments in the Schedule 8 register it was not for the reason of covering up but rather to rule off the register.

He thought the discrepancies to be minor clerical errors, he said, saying it was not until he read the AHPRA report that he realised the quantities involved were substantial.

In a 2017 statement, he said that the reason he pleaded guilty in the Magistrate’s Court was as part of the plea bargain, saying he had never actually supplied S8 drugs without a script.

He also said that he thought a former staff member, who is now overseas, could have taken the tablets.

The pharmacist also stated that he believed he used the scanner more often than alleged, but it malfunctioned.

In a statement to the Tribunal, he apologised for “letting the profession, the public and himself down”.

“In his last years, his dispensing practices and record keeping were not adequate to prevent the loss of medicines which are a risk to the community if misused,” the Tribunal noted he said in the statement.

“He did not take the risk of loss seriously enough even when he received a letter warning of the risk. Faced with the loss of medicines on a number of occasions he made the wrong decision. To make the register balance, he made false entries and inappropriate balancing entries and he under recorded the receipt of medication.

“On more than one occasion, he recorded the supply of all the Schedule 8 poisons listed on a Sigma invoice in the Schedule 8 register, but did not record the supply of Oxycontin which was supplied and listed on the same invoice,” the Tribunal noted.

“This did not seem to be an administrative oversight or a clerical mistake. Through his representative, [the pharmacist] claimed that he identified discrepancies in the register and rather than investigating them or reporting them, he put his ‘head in the sand’ and falsified the schedule 8 register to cover up the discrepancies.”

The Tribunal determined that the pharmacist should be reprimanded, and disqualified from applying for registration for 12 months.

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  1. Michael Khoo

    I have, and always will, regard his advice with the highest esteem. A real wake up call to keep a close eye on S8 balances given the exponential rise in the prescription volume of these drugs.

    • cathy beckhouse

      Agreed. I’ve always had the highest regard for Peter.

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