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A pharmacist who dispensed generic versions of prescription-only medicines (POMs) without a serious shortage protocol in place and supplied a POM at double the prescribed strength has been warned by a General Pharmaceutical Council fitness-to-practise hearing.

Christian Charles Logue admitted dispensing generic POMs when a branded version had been prescribed on one or more occasions between January 2023 and January 2024 while working as the superintendent and responsible pharmacist at Frodsham Pharmacy in Cheshire.

He also admitted labelling medication or permitting medication to be labelled “to reflect what was dispensed rather than what was prescribed”, although he denied his conduct was “dishonest”. 

Witnesses were aware of an issue with dispensing of medication

The committee heard evidence that the POMs prescribed which were substituted by Logue for generics included Bunov, Duotrav, Epilim, Kemadrin, Lorazepam, Monomil XL, Serevent, Sinemet, Tetralysal and Zapain.

Two witnesses who worked on medicines optimisation in care homes for NHS Cheshire and Merseyside said they became aware “of an issue with the dispensing of medication” at Frodsham Pharmacy in May 2022.

A pharmacist at Firdale Medical Centre which supports Davenham Hall care home told one of the witnesses a patient suffered an allergic reaction to a patch dispensed by the pharmacy.

That prompted the two witnesses to look into the dispensing of medicines by the pharmacy to Davenham Hall and other care homes including Gleavewood, Westwood Court and Lostock Lodge between May and August 2023.

The witnesses said they reviewed the GP’s prescription records and medication administration record charts at the care homes and examined the medication on the premises. Based on those investigations, one of the witnesses provided examples of medicines being dispensed “not as per prescription”.

Lorazepam 1mg tablets were dispensed when 500mcg had been prescribed

In other evidence, spreadsheets containing an entry relating to the dispensing of Lorazepam showed 500mcg had been prescribed but 1mg tablets were dispensed which had been split in half on August 7, 2023 when Logue was the RP at the pharmacy.

One of the witnesses also gave evidence that spreadsheets showed an item “prescribed on the GP system against the pharmacy dispensing label description on the medication” revealed “repeated instances” of labels “reflecting what was dispensed rather than what was prescribed between July 2022 and January 2024”.

The witness said they contacted NHS England with their concerns on March 14, 2022 and informed NHS Fraud. The witness also contacted the GPhC with concerns about patient safety but was not aware “of any harm caused to patients as a result of receiving a generic brand of medication and not what had been specifically prescribed”.

“The information gathered from (the witness’s initial visits showed that 27 different patients were involved in at least 31 separate instances,” a report into the committee hearing said.

I only ever tried to act in patients’ best interest, insisted pharmacist

In defence, Logue said he did not normally try to obtain prescription medicines from other pharmacies when he struggled to source them because “the pharmacy business has become more cut- throat than in the past” and he did not have “such close relations with other businesses” as a result.

He also said it was unlikely another pharmacy would be able to access medication he was struggling to source given he had contracts with nine wholesalers and suggested pharmacies would “unlikely want to part” with medicines that were in scarce supply.

The report said: “(Logue) did not think it practicable to request single medications from other pharmacies to fill blister packs for patients who were being dispensed a number of different medications, nor was it likely that other pharmacies would be willing to take on the dispensing of whole blister packs for individual patients.”

The committee also heard Logue thought “all of this could lead to complexity and delay”. Denying he had been dishonest, he insisted he had “only ever tried to act in his patients’ best interest”.

To reinforce this, he insisted there was evidence showing the generic versions he dispensed cost more than the medicines prescribed and as a result, his pharmacy “would have borne the additional cost”.

The committee said it had no concerns about Logue’s fitness to practise and recognised “no harm was caused to patients by the substitutions he made to prescriptions”.

“The committee is of the view that (Logue) is to be commended for the assiduous care he has taken to learn from his failings and improve his practice,” the report said, adding the committee was satisfied he had “remediated his misconduct and that it is highly unlikely he will repeat it in future”.

However, the committee said he “knowingly acted in contravention of regulations and guidance by dispensing alternative medications to those which had been prescribed”.

It ruled he breached three standards covering pharmacy professionals providing person-centred care, using their professional judgement and demonstrating leadership. Logue’s warning will be published in the register for 12 months.