Standard 1 – Pharmacy professionals must provide person-centred care
Standard 3 – Pharmacy professionals must communicate effectively
Standard 4 – Pharmacy professionals must maintain, develop and use their professional knowledge and skills
Standard 5 – Pharmacy professionals must use their professional judgement
Standard 8 – Pharmacy professionals must speak up when things go wrong
Standard 9 – Pharmacy professionals must demonstrate leadership
Case Summary
Allegations
In a disturbing and highly consequential case for pharmacy professionals, a pharmacist was found to have administered the wrong vaccine—a shingles vaccine (Zostavax) intended for older adults—to a 2-year-old child instead of the intended chickenpox vaccine (Varivax). The incident occurred while the registrant was working as a locum at Well Pharmacy in Plymouth.
The circumstances leading to the incident reveal a cascade of procedural failures:
The pharmacist failed to check the child’s identity (name and date of birth) before the administration.
There was no discussion with the child’s mother regarding the vaccine, its risks, or potential side effects.
Critically, no informed consent was obtained for the administration of Zostavax.
The pharmacist administered a vaccine not authorised under the relevant Patient Group Direction (PGD), despite not being an independent prescriber or having received proper training for administering vaccines to children.
The same needle was inserted multiple times, causing distress to the child.
No adequate clinical record of the appointment was made.
These actions were not just a deviation from best practice—they placed a vulnerable patient at significant risk.
Findings
The registrant admitted all allegations. The GPhC Fitness to Practise Committee found these failures amounted to serious misconduct. They concluded the pharmacist breached multiple professional standards, particularly around patient safety, informed consent, clinical judgment, and operating within one’s scope of practice.
Despite the admissions, the committee noted concerning gaps in the registrant’s understanding of what went wrong. Specifically, the pharmacist continued to claim Zostavax and Varivax were “the same vaccine with different branding,” an assertion clearly contrary to medical guidelines. Zostavax is not licensed for use in children and is indicated for preventing shingles in adults aged 70–79.
GPhC Determination on Impairment
The panel assessed the registrant’s fitness to practise as impaired on both personal and public interest grounds. They highlighted that the registrant demonstrated:
Limited insight: While he accepted wrongdoing and expressed remorse, his reflections lacked depth, especially regarding potential harm to the child and the seriousness of the errors.
Incomplete remediation: Though he had completed vaccine training post-incident, there was no evidence of CPD addressing the broader concerns, such as recordkeeping, informed consent, and resisting inappropriate pressure.
Risk of repetition: The panel was not satisfied that sufficient safeguards were in place to prevent future harm, noting the registrant had worked for four years since the incident without substantial development in insight.
“Given the limited insight and lack of remediation completed by the Registrant… the Committee considers that the Registrant’s conduct or behaviour may be repeated, which presents an actual or potential risk to patients or to the public.”
Sanction
The panel imposed a four-month suspension from the register, accompanied by an immediate interim suspension to prevent any ongoing risk during the appeal window. They judged that a suspension—rather than conditions or removal—was proportionate to protect the public and uphold professional standards.
The committee rejected lighter sanctions such as a warning or conditions, citing the attitudinal nature of the misconduct and the failure to “stamp authority” as the responsible pharmacist. They also determined removal was too severe, as the misconduct was remediable and the registrant had a previously unblemished 24-year record.
They set expectations for a future review, suggesting that the registrant should present evidence of:
Reflective work on professional judgement and patient safety
Leadership and safeguarding training
Strategies for responding to professional pressure
Key Learning Points for Pharmacy Professionals
This case carries significant lessons:
Always act within your scope of competence: Administering a vaccine for which you are not trained, particularly to a child, is a grave risk and regulatory violation.
Verify patient identity and obtain informed consent: These are non-negotiable elements of patient safety. Even if the patient is familiar, protocols must be followed.
Understand PGDs and legal frameworks: Vaccines must be administered only when legally authorised. Zostavax was not covered under the PGD and required a prescription.
Stand firm under pressure: Locums and responsible pharmacists must maintain their autonomy and uphold standards, even when pressured by colleagues or workflow issues.
Comprehensive documentation is essential: Accurate recordkeeping protects both patient and practitioner. The absence of a clinical record was a significant concern in this case.
Post-incident reflection must be deep and honest: Insight goes beyond apologies. It requires recognition of the risks posed, acknowledgment of harm, and demonstrable learning.
Clinical knowledge must be current and evidence-based: Zostavax and Varivax are not interchangeable. Pharmacists must ensure they are using the right product for the right indication, supported by guidance like the BNF.
This case serves as a stark reminder of the weight pharmacists carry in ensuring safe, lawful, and ethical practice. While the pharmacist involved expressed remorse, the seriousness of the errors—and the vulnerability of the patient involved—necessitated regulatory intervention.
Original Case Document
The full determination transcript is available to logged in users.
