Pharmacist suspended for remote WhatsApp monitoring “on the toilet”

A pharmacist has been suspended for five months for making “numerous failings” and behaving as a “poor manager” at a GPhC fitness to practice (FtP) hearing that spanned several weeks in May and June.

His “failures,” according to hearing documents, included remotely checking medications via WhatsApp, allowing drug delivery without an on-site pharmacy, keeping false records and allowing a patient to take home medications he should have taken under supervision.

The FtP Committee concluded that Mahmoud Muhiyye (registration number 2211528) was “completely out of his depth” when he was appointed senior pharmacist (SI) and pharmacist-in-charge (RP) of Cale Green Pharmacy in Stockport – owned by his brothers, who are not pharmacists – in June 2018.

The committee heard that Muhiyye, who had graduated just two years earlier in 2016 and had previously “only worked as a pharmacist’s locum”, had been “running the pharmacy via WhatsApp messages” after the pharmacy’s trainee pharmacist lodged a complaint with the regulator in July 2019.

An unannounced visit by an NHS England (NHSE) official and a controlled drugs liaison officer in the same month resulted in the council finding that Muhiyye had failed to “ensure the safe custody of controlled drugs” and “employed inexperienced staff” who it had instructed to “act beyond their competence”.

During the hearing, concerns were raised about the “unreliability” of evidence provided by two former employees, as both the trainee pharmacist and the qualified part-time pharmacist had left their jobs “in dispute” with Muhiyye and each other following “a dispute between the three of them”.

But despite the “collapse of hierarchical boundaries”, the GPhC ultimately stressed that “the burden of proof lies with the Council”.

The regulator acknowledged that there was “no evidence that patients had been harmed by Muhiyye’s actions”, that it was unlikely that he would repeat his misconduct and that he had “shown genuine insight and expressed remorse and regret”.

However, it was stressed that these were “serious and wide-ranging violations, representing numerous examples of poor pharmacy practices” over a “period of several months”.

The committee heard that the trainee pharmacist “had sent the registrant photos of the medicines for review via WhatsApp” and that she “had not been aware that the pharmacist was supposed to be present in person to carry out the final check”.

Muhiyye told the committee he had started authorising the delivery of medicines via WhatsApp “when he was too busy”, adding that it was “a mistake to keep allowing this” and it had become “a bad habit”.

“The language used and the nature of the WhatsApp messages were indicative of his lack of professionalism and immaturity,” the GPhC said.

It went on to say that he “was apparently in the toilet at one point when he authorized the delivery of medication to a patient based on WhatsApp photos.”

“The committee was convinced that this was not adequate oversight,” it said.

It also stated: “It is more likely that the registrant was not present on most of the days the photos were sent.”

In total, 16 cases were identified in which Muhiyye “caused or permitted the supply or sale” of controlled drugs (CDs), prescription-only medicines (POMs) and pharmacy-only medicines (P-Meds) while no pharmacist was on site.

In 18 cases, he “used an electronic messaging system to check the medications” while he was not on site, it said.

“The private personal and medication data of numerous patients were stored on an employee’s personal device for several months, even after the employee had left the pharmacy,” it said.

“During his testimony, the defendant admitted that he had allowed a patient to take buprenorphine medication home,” the committee said.

“He confirmed that this was the patient’s first dose and that it was given at the beginning of Ramadan when the patient was fasting,” it said.

And it found that in 2019 he “demanded payment for an item that had not been delivered” – even though the claim was an “error” and he himself had paid for a related penalty fee.

It stated that the registered person had failed “in at least one case” to ensure the safe storage of CDs and had failed to adequately control access to the keys to the CD cabinet.

And he “did not record his absences during his activity as RP in the RP minutes”.

The GPhC considered that Muhiyye had “taken on far too much at an early stage of his career without a real understanding of the responsibilities of the roles of RP and SI”.

However, it was also stressed that “inexperience and naivety are no excuse for taking on the responsibility of managing a pharmacy and then failing to meet standards.”

When concerns were raised, Muhiyye took “immediate action”, resigning from his position as SI in August 2019 and no longer being involved with the pharmacy, although he had regularly worked as a substitute doctor at various pharmacies since the events, according to the document.

The committee said Muhiyye was “a poor manager, with little experience in managing staff, let alone running a pharmacy.”

However, it was said that he was a “good pharmacist” who had “learned a very salutary lesson from these events” and had since received “excellent testimonials” from colleagues.

Muhiyye has “admitted his mistakes,” acknowledged that he had shown “poor judgement” and now feels “shame” and “guilt” about the events. He has also taken “significant steps to make amends,” it said.

The court concluded that despite the “serious misconduct”, “stripping from the register would be a disproportionate punishment”.

It was decided that Muhiyye should be excluded from the GPhC register “for a period of five months”.

The full decision can be found here.