A pharmacist who dispensed fentanyl and other controlled drugs to a patient against falsified prescriptions over a one-year period without spotting several “red flags” has been suspended for six months by the GPhC.

West Midlands pharmacist Jagjit Sihota attended an in-person fitness to practise hearing at the regulator’s London headquarters on July 5-6, during which the FtP committee considered allegations that he had breached professional standards while working as the superintendent and responsible pharmacist at Al-Shafa Pharmacy in Walsall.

The FtP committee heard that Mr Sihota had supplied controlled drugs to Patient A “against a number of prescriptions which contained various handwritten amendments which had not been made by the prescriber” between January 2018 and February 2019.

These handwritten amendments to electronic prescriptions included instructions around the date of issue, the quantity or strength of prescribed medications and the addition of new medications. The “vast majority” of the amendments concerned Actiq (fentanyl) lozenges or fentanyl sublingual tablets, although some were in relation to tramadol capsules and amitriptyline tablets.

A GPhC inspector who reviewed a sample of 32 out of 87 prescriptions presented by Patient A at the pharmacy concluded that a number of them did not comply with regulations and were therefore invalid, as they failed to specify crucial information like the date, dose, form or name of the medication or because the prescription had expired.

The inspector also considered that Mr Sihota should have been prompted to check the validity of some prescriptions because of “unusual” matters such as the handwritten amendments and lack of counter signatures; in some cases, the printed name of the prescriber “was not necessarily the prescriber”.

Investigation

An investigation was started when Mr Sihota himself contacted the local NHS team with concerns around prescriptions he had received from Patient A in “about February 2019”.

An NHS counter fraud specialist then reviewed some of the prescriptions and concluded that it was “obvious” that they were “not legitimate”. The Village Medical Centre, which has issued some of Patient A’s prescriptions, confirmed that the handwritten amendments were not genuine.

When the investigator went back to Mr Sihota, he explained that the Patient had attended the pharmacy for many years and that he “was well spoken and well-presented and had had a motorcycle accident which explained his need for the drugs”.

‘Gross falling short’

Representing the GPhC, lawyer Matthew Corrie said Mr Sihota’s conduct amounted to a “a gross falling short of the standard required of a pharmacist” and that he had been “blind” to issues with the prescriptions that should have been apparent.

Mr Sihota, who admitted to all the allegations against him, told the hearing that he felt “physically sick” with his actions and embarrassed that he had allowed himself to be manipulated by Patient A, who he viewed as a mentor within their community and who now faces criminal proceedings. He said that during the relevant period he had been under personal stress and was working excessive hours, and the FtP committee accepted this as a contributing factor.

While the FtP committee noted Mr Sihota’s previously unblemished record, sincere insight and deep reflection into his misconduct and that he has taken “extensive steps” to remedy his conduct such as working with local addiction services, it agreed with Mr Corrie that the seriousness of having inappropriately dispensed controlled drugs amounted to a failure to honour “core pharmacy practice”.

It found he had breached a number of professional standards, most seriously in what it described as his failure to use professional judgement and be “objective about Patient A’s care,” and that sanctions were therefore needed to uphold the public interest.

Having considered that there is “minimal risk” of the misconduct being repeated, the committee decided that Mr Corrie’s request for a 12-month suspension was “disproportionate” and imposed a six-month suspension with no requirement for a review before Mr Sihota can return to practise.