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A locum pharmacist who gave a two-year-old child a vaccine which is used to treat adults with shingles believing it was effective against chickenpox has been suspended by the General Pharmaceutical Council for four months.

During a fitness-to-practise committee hearing last month, Kofi Akuamoah Boahene admitted failing to check the child’s name and date of birth before administering the vaccination while working at Well Pharmacy in Plymouth in August 2021.

He also failed to explain the vaccine’s risks to the patient’s mother, did not obtain her consent to administer Zostavax to the child and administered the vaccine even though it was not prescribed or covered under a patient group direction (PGD).

Boahene, who was not an independent prescriber, said he ordered Zostavax because Varivax, a vaccine that prevents chickenpox, was out of stock and believed Zostavax was an alternative having looked at the British National Formulary.

He admitted failing to check and review the PGD on Varivax before the child’s appointment and make an adequate record of the appointment and admitted inserting the same needle into their skin on two or more occasions.

He maintained Zostavax was effective against chickenpox even though it was not listed in the PGD and insisted he told staff at the pharmacy that he did not have “specific training to administer chickenpox vaccines, only training to administer flu vaccines”.

Boahene, who has been a pharmacist for 24 years, claimed staff insisted he administer the chickenpox vaccine although he conceded he failed to ask an area manager or superintendent pharmacist for help.

What happened?

Giving evidence to the hearing, the child’s mother said she made an online booking in July 2021 for the child to have a private vaccination for chickenpox at the pharmacy. As part of the booking, she filled in a questionnaire relating to the administration of the vaccine and after making the booking, she was called by the pharmacy who told her the vaccine needed to be ordered.

The mother called the pharmacy back to ask where on her child’s body the vaccine would be administered so she could apply numbing cream to reduce pain caused by the injection.

The mother claimed she overheard someone in the pharmacy say “oh, I haven’t given that vaccine before, is it given in the buttock?” A member of the pharmacy’s staff later confirmed to the mother it would be administered in the arm.

The Committee heard when she came to the pharmacy with her child on August 2, 2021, she was told there was “an issue with the plunger” and her appointment needed to be rearranged. The next day, the pharmacy called the mother to say the vaccine was ready and they came in for the appointment.

The mother said that when they came into the room for the vaccination, “aside from an apology for not having given the vaccine the day before, there was no additional discussion” with Boahene “or questions” about the child’s “identity including their date of birth, details of the vaccine, risks of the vaccine or confirmation of consent”.

The mother said Boahene “stuck the same needle” into her child’s arm “a few times causing (the child) to cry out in pain”. A report into the hearing said: “The registrant attempted to inject the upper left arm using the same injection twice and that the needle went in but not deep enough to administer the vaccine.

“He once again pulled the needle out and went back in again with the same needle to complete. the administration of the vaccine.”

The Committee heard that after the vaccine had been administered, the mother asked for details of the vaccine so she could update her GP and was given a post-it note.  “It was only at this point the registrant asked for (the child’s) name and date of birth,” the report said.

The mother said Boahene did not seem to know when the second vaccine was due and after leaving, she looked up the vaccine written on the note and found it was not the chickenpox vaccine Varivax which she insisted was what they were booked in for but Zostavax.

The hearing was told the child “developed strange red and purple spots on their forehead, scalp and behind the right ear” two hours after the vaccine had been administered and was taken to A&E on the advice of NHS 111. The child spent nine hours in A&E and was discharged after the rash did not get worse.

Naturally upset the child suffered immediate distress

The report said Boahene recognised “it was completely wrong to have acted outside of his competence” and was “naturally upset” the child “suffered immediate and ongoing trauma and distress as a result of the vaccination he administered.”

However, the Committee was concerned that he “still maintains the position that Zostavax and Varivax vaccines are medically the same when they are different vaccines for different patient age ranges”.

Taking into account the incident occurred four years ago, Boahene’s “unblemished professional record” and the fact he completed training to administer chickenpox vaccines, the Committee concluded his “conduct and behaviour presented an actual risk of harm to patients and the public”.

He did not return to work at the pharmacy after the incident but worked at other branches of Well in Plymouth and Devon over the next couple of years and now works for Boots.