Pharmacist Suspended for Two Months After Administering Incorrect Flu Vaccines and Falsifying Records

The General Pharmaceutical Council (GPhC) Fitness to Practise Committee investigated a pharmacist after he administered the incorrect flu vaccine to elderly patients and falsified vaccination records.

Between 1 and 15 October 2018, while working at Rowlands Pharmacy in Overton, Wales, the pharmacist:

1. Administered Quadrivalent flu vaccines instead of Fluad, which was required for:
   • Patients 75 years and older.
   • Patients 65 years and older in clinical risk groups.
2. Recorded on patient consent forms and the Choose Pharmacy platform that Fluad was administered when, in fact, Quadrivalent was given.
3. Knowingly acted dishonestly by documenting incorrect information.
4. Failed to collect emergency contact details for some patients receiving the incorrect vaccine.

The issue was identified when Rowlands Pharmacy management conducted an audit on 17 October 2018 and found that more Fluad vaccines were recorded in patient records than had been received into stock.

During an internal investigation on 19 October 2018, the pharmacist admitted that he:

• Knew patients were supposed to receive Fluad.
• Told patients they were getting Quadrivalent but documented Fluad instead.
• Misrepresented vaccine batch numbers in patient records.

He later resigned in December 2018 following the internal investigation.

Findings:

The Fitness to Practise Committee determined that the registrant’s actions amounted to serious misconduct, particularly:

1. Failure to Follow National Flu Vaccination Guidelines:
   • The PGD explicitly required Fluad for certain patient groups, and the pharmacist knowingly ignored this guidance.
2. Falsifying Patient Records:
   • The registrant documented Fluad instead of Quadrivalent, creating a false medical history that could mislead GPs.
3. Dishonesty and Cover-Up:
   • Instead of admitting the error, the pharmacist intentionally altered patient records to cover up mistakes.
   • He later admitted that fear of getting into trouble influenced his actions.
4. Risk to Patient Safety:
   • Patients who should have received Fluad did not get the proper level of flu protection.
   • Incorrect vaccine records could have led to medical errors if patients required further care.

Despite these findings, the committee acknowledged mitigating factors:

• The pharmacist expressed deep remorse.
• He took steps to improve his record-keeping and compliance with PGDs.
• There was no evidence of actual patient harm, although some patients had to be re-vaccinated.

GPhC Determination on Impairment:

The committee found the pharmacist’s fitness to practise impaired, emphasizing that:

• Dishonesty is a serious issue, even when there is no financial gain.
• The registrant’s conduct undermined trust in the profession.
• Accurate patient records are critical to ensure safe and effective healthcare.

However, the committee also acknowledged significant remediation efforts, noting that the pharmacist:

• Completed additional training on vaccination procedures and record-keeping.
• Provided positive testimonials from employers and colleagues.
• Refused a managerial role at another pharmacy, recognizing that he needed more experience before taking on additional responsibilities.

Given these factors, the committee ruled that suspension was necessary but that removal from the register was not warranted.

Sanction:

The committee imposed a two-month suspension, considering:

• Aggravating Factors:
  • The pharmacist knowingly falsified patient records.
  • He failed to self-report the issue immediately.
  • Some patients were in clinical risk groups, making accurate vaccination records even more critical.
• Mitigating Factors:
  • The pharmacist admitted his wrongdoing early.
  • He expressed genuine remorse and took corrective action.
  • He had no previous fitness to practise concerns and received positive employer testimonials.

Key Learning Points for Pharmacy Professionals:

This case highlights important lessons for pharmacists regarding professional ethics, vaccination procedures, and record-keeping.

1. Always Follow National Vaccination Guidelines:
   • The PGD exists to protect patient safety—deviating from it can result in disciplinary action.
   • If a required vaccine is out of stock, pharmacists should consult supervisors before offering alternatives.
2. Never Falsify Patient Records:
   • Accurate documentation is essential for patient safety.
   • Misleading information in medical records can have serious consequences, including incorrect treatment decisions.
3. Honesty and Transparency Are Critical in Pharmacy Practice:
   • The GPhC takes dishonesty seriously, even when no financial gain is involved.
   • Admitting mistakes early can lead to reduced sanctions.
4. Workload Pressures Are Not an Excuse for Poor Decision-Making:
   • The registrant cited high workload and personal stress as contributing factors, but the committee emphasized that professional standards must be upheld at all times.
   • Pharmacists should seek managerial support when feeling overwhelmed.
5. Regulatory Sanctions Can Serve as a Learning Opportunity:
   • The pharmacist avoided removal, but his suspension serves as a warning to others about the importance of professional integrity.
   • Demonstrating insight, remorse, and a commitment to improvement is key to rehabilitation.