Pharmacy Council complaints about a pharmacist: six stages from notice to outcome

Most pharmacists first learn of a complaint through a letter from the Health and Disability Commissioner (HDC) or the Pharmacy Council, or from their employer. It is natural to want to reply straight away. A short pause to organise yourself usually leads to a better response.

• Read the letter twice and note who sent it, what it asks for, and the date a reply is due.
• Get advice early. The Council's own guide, A complaint has been made about me, suggests the Pharmacy Defence Association for members, a lawyer with health law experience, and experienced peers. The Pharmaceutical Society of New Zealand (PSNZ) is the profession's membership body and can point members to support.
• Secure the facts, not the story. Gather the dispensing record, prescription, labels, counselling notes, rosters and any incident report. Do not alter or add to records after the event; if something needs clarifying, write a dated addendum that is clearly marked as later.
• Leave the complainant alone unless your adviser has agreed that some contact is appropriate.Look after yourself. The Council acknowledges that any formal process is stressful and recommends professional support.

The Council also says it must stay impartial, so while it can explain the usual process it cannot advise you on how to respond or predict the outcome. That is why independent advice matters.

Concerns about a pharmacist arrive by several routes under the Health Practitioners Competence Assurance Act 2003 (HPCA Act):

• A complaint from a patient or member of the public, either to the Council or, more often, to HDC.
• A notification about competence from another health practitioner or an employer. A pharmacy or hospital employer that dismisses a pharmacist, or accepts a resignation, over competence must report it to the Council.
• A conviction. The Council's guide says courts notify it of convictions for offences punishable by three months' imprisonment or more, and of offences under certain Acts.
• A health notification, where a condition may affect your ability to practise safely.
• Issues found through other regulators, such as a Medsafe audit or pharmacy licensing inspection, which have featured in several Tribunal cases.

Complaints that a pharmacist's practice or conduct affected a patient are passed by the Council to HDC, and the Council holds off until HDC has decided, with interim public-protection powers the only exception.

After preliminary enquiries, HDC chooses between closing the file, sending the matter to the Health and Disability Advocacy Service, refer it back to the Council, make recommendations such as an apology or service changes, or open a formal investigation. HDC's guidance for providers, What if a complaint is made about me?, says supplying the information it asks for does not breach privacy or confidentiality, and encourages low-level resolution where possible.

In a formal investigation, HDC reports whether there was a breach of the Code of Health and Disability Services Consumers' Rights. The Council's guide notes HDC may publish its findings for educational purposes without naming the pharmacist, and may refer serious breaches to its Director of Proceedings, who can lay a charge before the Health Practitioners Disciplinary Tribunal.

When a complaint comes to the Council for its own consideration, you are usually invited to make a written submission before it decides what to do. This is your first chance to show the Council how you have responded to what happened. A useful submission is factual, acknowledges the patient's experience, explains what you have reviewed (for example a root-cause analysis of a dispensing incident), and sets out what you have changed and learned.

The Council then decides whether a formal process is needed. Some matters can be resolved informally where both parties agree. Others go down one of three pathways: competence, conduct or health. Where it judges that the public may be at risk, the Council can also make interim orders and may notify others such as ACC, HDC, the Director-General of Health and your employer.

Where a concern is about the standard of your practice, the Council may make enquiries, ask for a practice visit with your consent, and then direct that your competence be reviewed under s 36 of the HPCA Act. You get notice and the chance to be heard, and you may bring a support person (s 37). The Council's guide says the review is carried out by two experienced practising pharmacists. You receive their report, can make written submissions, and meet the Council's Competence and Fitness to Practise Committee (CFPC).

If the review finds your practice falls below the required standard, the orders available under section 38 include:

• a competence programme to address the specific gaps;
• conditions on your scope of practice, for example practising only under supervision;
• an examination or assessment; and
• counselling or assistance.

Should serious harm seem possible mid-review, section 39 permits suspension or conditions on an interim basis. A pharmacist who does not finish a competence programme may face more conditions or suspension, but that failure alone cannot found a disciplinary charge. Competence and health pathways are designed to be supportive. Health concerns, for example, can often be managed through a voluntary written arrangement, and the Council meets the cost of any independent health assessment it orders.

If a complaint raises questions about your conduct or the safety of your practice, or follows a conviction, the Council may refer it to a Professional Conduct Committee (PCC). The Council's committees page explains that a PCC is made up of two registered pharmacists and one lay member drawn from a trained pool, and is the only body in the process with statutory investigative powers. It acts independently of the Council.

A PCC can appoint investigators and legal advisers, require information and statutory declarations, and gather evidence from you, your employer, the complainant and clinical experts. You are kept informed and can make submissions in person or through a lawyer. At the end, it may:

• decide no further steps are needed;
• recommend a competence review, conditions on your scope, or counselling by an experienced pharmacist;
• refer the matter to conciliation;
• recommend referral to the Police; or
• lay a charge before the Tribunal.

Separately, under section 69 the Council may suspend a pharmacist or attach conditions to their practising certificate until the end of the PCC investigation or a prosecution, if what is alleged makes the Council doubt that your professional conduct is appropriate.

Charges against pharmacists are heard by the Health Practitioners Disciplinary Tribunal (HPDT), the single tribunal for all regulated health professions. A panel for a pharmacist's hearing includes the chair or a deputy chair, three pharmacists and one layperson.

Grounds (s 100)

Most charges allege professional misconduct, either negligence and malpractice (s 100(1)(a)) or conduct that has harmed, or could harm, the standing of pharmacy (s 100(1)(b)). Other charges rest on relevant convictions, dispensing or practising without a current APC or beyond scope, and breaches of conditions or orders. The Tribunal applies a two-step test: does what the pharmacist did fall into one of those categories, and if it does, is it far enough below standard to need a penalty?

Penalties (s 101)

Penalty decisions follow principles set out in Roberts v Professional Conduct Committee [2012] NZHC 3354: protecting the public, maintaining standards, rehabilitation where appropriate, consistency, and choosing the least restrictive penalty that is proportionate. Decisions are published; name suppression must be applied for. Appeals from the Tribunal go to the High Court; certain Council decisions can be appealed in the District Court. The Council also has a reconsideration process and will tell you when appeal rights apply.

The Pharmacy Council publishes HPDT decisions about pharmacists, usually as summaries. Reading several recent ones shows recurring patterns. We describe them generally here and give the decision numbers so you can read the source.

• Misleading a regulator or auditor. In Phar25/633P an intern pharmacist who dispensed methadone without supervision gave a Medsafe auditor a false name. The penalty included censure, a six-month mentoring programme and disclosure of the decision to employers. In Phar22/561P, false information to the Council and Medicines Control and copied professional development records formed part of a case that ended in cancellation.
• Taking or supplying medicines. Phar25/639P involved removing sedative medicines for personal use and supplying a prescription medicine to a colleague without a prescription. The Tribunal ordered censure, a year without sole-charge practice, 12 months of mentoring with monthly self-reflection reports, and disclosure to employers.
• Theft and resale. In Phar21/533P, ordering unnecessary stock and selling it online led to cancellation, with approved training on legal and professional obligations required before any re-registration.
• Pharmacy operations and supervision. Phar22/568P concerned unsafe dispensing, controlled medicine handling, unsupervised staff and remote supervision from overseas, alongside misleading information to auditors. Registration was cancelled.
• Financial dishonesty. In Phar25/654P a pharmacist's personal bank details on a primary care funding form diverted payments meant for the employer, leading to a conviction, censure, costs and a requirement to disclose the decision to prospective employers if seeking to practise in New Zealand again.

Two lessons stand out. First, dishonesty after the event, whether to an auditor, the Council or in records, repeatedly turns a fixable problem into a serious one. Second, where practitioners kept their registration, the orders were often educational: mentoring, structured reflection and supervision. Engaging with that kind of learning early, and being able to explain what has changed, is consistent with what the Tribunal looks for.

Each year your practising certificate application asks you to declare that you are fit to practise. According to the Council, an untrue or misleading answer can lead to the application being refused. If you are under investigation, have conditions, or have a conviction or health issue the Council should know about, answer the questions fully and accurately, and take advice if you are unsure how a question applies. Leaving something out tends to become a second, separate concern. Our Pharmacy Council recertification guide covers the routine renewal requirements.

Neither the Council nor the Tribunal requires you to take a course in response to a complaint, and nothing you do guarantees an outcome. But a clear record of what you have learned and changed can help you explain your position honestly at each stage. A practical approach:

1. Name the gap precisely. For example, "checking controlled drug entries at the end of each shift", not "general carelessness".
2. Learn against the standard. Link your learning to the Code of Ethics 2018 and the 2023 Competence Standards.
3. Change something you can show. A revised checking procedure, a new counselling script, or an audit of your own records.
4. Write a reflection that is about learning, not blame. De-identify patients and assume it may be read by others.
5. Keep certificates and dates so your adviser can present them if appropriate.