‘Obviously defeated the safe’s main purpose’: Manitoba pharmacist fined $15,000 after routinely leaving narcotic safe unlocked

A Winnipeg pharmacist has been fined $15,000 after pleading guilty to professional misconduct involving hundreds of unexplained narcotic inventory discrepancies, some involving thousands of doses.In a disciplinary decision dated July 9, the College of Pharmacists of Manitoba also ordered Mandeep Kaur to pay $10,000 toward investigation and hearing costs following a hearing in April 2026. The college also ordered publication of her name and the circumstances of her misconduct.Kaur was pharmacy manager at a Shoppers Drug Mart on Main Street in Winnipeg from March 2022 to November 2023. During that time, the college found she failed to investigate 225 discrepancies in the pharmacy’s narcotic inventory, many involving “hundreds or thousands of doses.”“None of these discrepancies had a documented investigation to determine the reason for the discrepancy,” the disciplinary panel wrote.“Few of the many unexplained shortages were reported to Health Canada, and none were reported to the College as required.”Investigators also found that the pharmacy’s time-delayed narcotic safe was left unlocked and ajar on several occasions, including when Kaur was absent.Kaur told an investigator the safe was routinely left open during business hours because of the wait required to unlock it. The panel said the practice “obviously defeated the safe’s main purpose.”In determining the penalty, the panel acknowledged that Kaur had accepted responsibility for her misconduct and taken steps to improve her professional knowledge.A missed medication, another surgeryThe college also found that Kaur failed to maintain ongoing inventory records for two Methadose formulations or complete required quarterly physical counts for approximately a year.Beyond narcotic inventory management, the decision identified additional failures involving medication safety procedures, patient counselling and staff supervision.One incident involved a patient who had undergone cardiac surgery and was prescribed seven medications upon discharge.“When the prescriptions were filled, one of the medications was out of stock at the Pharmacy,” the panel wrote. “This fact was missed by the staff pharmacist who filled the prescription, and the medication was not provided or flagged as missing.”The patient went without the medication for an unknown period before suffering a thrombotic event that required surgery. The panel found that Kaur later filled the missing prescription but did not counsel the patient or the person collecting the medication, despite knowing about the earlier error.New to Manitoba, but responsible for the pharmacyThe college also found gaps in patient counselling records: an audit of 48 new prescriptions from January 2023 found documentation of counselling on only four occasions.Kaur also admitted to making a false declaration on the pharmacy’s 2023 licence renewal application, stating that required safety assessments and an annual quality improvement meeting had been completed when they had not.In its decision, the panel acknowledged that Kaur had been registered as a Manitoba pharmacist for only four to five months when she became pharmacy manager. It also recognized that her employer and mentor had placed her in a difficult position by asking her to take the role and promising to handle certain responsibilities, including narcotic counts, that were not completed.However, the panel said Kaur should have declined the position if she was not confident she could fulfill its responsibilities.“Having accepted the role, she was obligated to comply with the role’s responsibilities, which she failed to do,” the panel wrote. “The role of pharmacy manager is central to the safe and effective operation of a pharmacy in Manitoba.”It also noted that Kaur remained in the position for approximately 20 months, during which few, if any, steps were taken to address the problems.“Pharmacists who assume the role of pharmacy manager must not do so lightly,” the panel wrote.

‘Obviously defeated the safe’s main purpose’: Manitoba pharmacist fined $15,000 after routinely leaving narcotic safe unlocked

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