Locum Pharmacist Suspended After Administering Shingles Vaccine to Child Under Wrong PGD at Well Pharmacy
Date of Decision: August 28, 2025
Registrant's Role: Pharmacist
Allegations:
- Administered Zostavax (a shingles vaccine intended for adults) to a 2-year-old child instead of the prescribed Varivax (chickenpox vaccine)
- Failed to check the child’s name and date of birth before administering the vaccine
- Did not obtain informed consent from the child’s mother
- Did not explain the risks associated with the vaccine
- Administered a vaccine not covered by a Patient Group Direction (PGD)
- Inserted the same needle multiple times into the child's arm during vaccination
- Failed to review the relevant PGD before the appointment
- Acted outside his scope of competence (not an independent prescriber and lacked training)
- Did not make an adequate clinical record of the appointment
Outcome: Suspension – 4 months (with immediate interim suspension)
GPhC Standards Breached:
- 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:
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- Full allegations considered by the GPhC
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Original Case Document
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