1 Aug 2025 Margaret Ann MCNAUGHTON · Prevention of Future Deaths report Black Country
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Concerns raised 2
Failure to require prescriber recording of allergy-status verification before prescribing View source Failure to implement a Trust-wide process for checking and recording patients’ allergy status View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
The Trust
Incorporate the drug-allergy “HOW to” guidance into Trust policy, including mandatory completion of allergy information before prescribing or administration.
View source
The Trust
Review paper prescription charts and improve allergy documentation by adding space to record the information sources checked.
View source
The Trust
Provide Emergency Department pharmacist capacity to oversee allergy documentation and train clinical staff.
View source
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Margaret Ann MCNAUGHTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Ann MCNAUGHTON was admitted to hospital with breathing difficulties and a respiratory infection, with a known penicillin allergy recorded in available clinical records. She was prescribed and given intravenous co-amoxiclav before being seen by a clinician, suffered cardiac arrest from penicillin anaphylaxis, and died in hospital on 13 December 2024 after deteriorating with respiratory failure. The principal concerns were failures to check and document her allergy status before prescribing, and the absence of sufficiently clear and embedded Trust processes and policies for carrying out and recording such checks, with further medication allergy incidents reported.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to require prescriber recording of allergy-status verification before prescribing
Wider context from the report “5. I am concerned that an email to all clinicians and a ‘message of the week’ does not go far enough in terms of the ensuring the Trusts own recognition of ‘lessons learned’ has been embedded across the Trust and that the requirements to check a patient’s allergy status and record the findings and has not been enshrined in any Trust Policy.
6. Given the findings of the Trust from February 2025 and the date of the email sent by the Clinical Director in April 2025, the inference is that such further incidents have taken place after the death of Mrs McNaughton and AFTER the message of the week and AFTER the February 2025 audits. Although there is evidence that auditing is taking place, given incidents are continuing to occur I am concerned this presents and continues to present a risk to patient safety at this time.
7. The Trusts Policy on Prescribing, storage and administration of drugs states; ‘it is the responsibility of a registered medical or dental officer to prescribe for a patient It is the responsibility of the prescriber to take a medication history and complete the drug allergy box’. Again, whilst accepting this I cannot see anything in this policy that addresses my concern as to HOW this is carried out.
8. The Trusts Policy on Electronic Prescribing and Medicines Administration (ePMA) Policy outlines how the ePMA system must be used within the Trust. It provides an electronic system for prescribing, clinical checking, supplying, and administering medication. The Policy states that the system must enable the Trust to reduce the risk of medication errors and that the ePMA system also provides a Decision Support System (DSS) to aid safer prescribing and administration. The Policy states ‘Prescribers are responsible for entering allergy details into the patient’s medical record within ePMA as part of their clerking, and thereafter regularly reviewing the allergy details.’ Again, whilst accepting this I cannot see in this policy anything specific about HOW such checks should be carried out and when.
9. The Trusts Management of Medication Errors Policy states; it is the responsibility of a registered medical [or dental] officer to prescribe for a patient. It is the responsibility of the prescriber to take a medication history and complete the drug allergy box’ again accepting this, the policy otherwise deals with how errors are reported and dealt with, and does not appear to cover my concerns outlined above.
10. I cannot see any Trust Policy that provides guidance on HOW a patients allergy status should be checked or recorded and by whom and where - over and above a prescribers professional responsibility and accountability.
11. I am concerned that it remains unclear as to how such checks should be carried out (e.g use of CWP; two sources, timing of the recording of information etc..) and where information about such checks should be recorded. I am concerned this presents a risk to patient safety at this time.
12. I am also concerned that there is no apparent requirement for a prescriber to record that they have either checked the patient’s allergy status themselves before prescribing OR checked the source of the information contained within the hospital records . I am concerned this presents a risk to patient safety at this time.
” Source location Margaret Ann MCNAUGHTON · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to implement a Trust-wide process for checking and recording patients’ allergy status
Wider context from the report “5. I am concerned that an email to all clinicians and a ‘message of the week’ does not go far enough in terms of the ensuring the Trusts own recognition of ‘lessons learned’ has been embedded across the Trust and that the requirements to check a patient’s allergy status and record the findings and has not been enshrined in any Trust Policy .
6. Given the findings of the Trust from February 2025 and the date of the email sent by the Clinical Director in April 2025, the inference is that such further incidents have taken place after the death of Mrs McNaughton and AFTER the message of the week and AFTER the February 2025 audits. Although there is evidence that auditing is taking place, given incidents are continuing to occur I am concerned this presents and continues to present a risk to patient safety at this time.
7. The Trusts Policy on Prescribing, storage and administration of drugs states; ‘it is the responsibility of a registered medical or dental officer to prescribe for a patient It is the responsibility of the prescriber to take a medication history and complete the drug allergy box’. Again, whilst accepting this I cannot see anything in this policy that addresses my concern as to HOW this is carried out.
8. The Trusts Policy on Electronic Prescribing and Medicines Administration (ePMA) Policy outlines how the ePMA system must be used within the Trust. It provides an electronic system for prescribing, clinical checking, supplying, and administering medication. The Policy states that the system must enable the Trust to reduce the risk of medication errors and that the ePMA system also provides a Decision Support System (DSS) to aid safer prescribing and administration. The Policy states ‘Prescribers are responsible for entering allergy details into the patient’s medical record within ePMA as part of their clerking, and thereafter regularly reviewing the allergy details.’ Again, whilst accepting this I cannot see in this policy anything specific about HOW such checks should be carried out and when.
9. The Trusts Management of Medication Errors Policy states; it is the responsibility of a registered medical [or dental] officer to prescribe for a patient. It is the responsibility of the prescriber to take a medication history and complete the drug allergy box’ again accepting this, the policy otherwise deals with how errors are reported and dealt with, and does not appear to cover my concerns outlined above.
10. I cannot see any Trust Policy that provides guidance on HOW a patients allergy status should be checked or recorded and by whom and where - over and above a prescribers professional responsibility and accountability.
11. I am concerned that it remains unclear as to how such checks should be carried out (e.g use of CWP; two sources, timing of the recording of information etc..) and where information about such checks should be recorded. I am concerned this presents a risk to patient safety at this time.
12. I am also concerned that there is no apparent requirement for a prescriber to record that they have either checked the patient’s allergy status themselves before prescribing OR checked the source of the information contained within the hospital records. I am concerned this presents a risk to patient safety at this time.
” Source location Margaret Ann MCNAUGHTON · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate the drug-allergy “HOW to” guidance into Trust policy, including mandatory completion of allergy information before prescribing or administration.
Verbatim wording from the response “• A Short Working Life Group was set up with the specific remit for identification and recording of drug allergies. The group had representation from the multi-professional team and was led by the Chief Pharmacist. The group reviewed the current practice, including how Trust IT systems interact to inform the process for checking and recording drug allergies.” Source location Response from Royal Wolverhampton NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review paper prescription charts and improve allergy documentation by adding space to record the information sources checked.
Verbatim wording from the response “administered unless allergy status information is completed’ as an additional control measure.
Documentation: a review of paper prescription charts (where ePMA is unavailable) is underway which will improve the recording of a patients allergy status and will include space to record the information sources checked.” Source location Response from Royal Wolverhampton NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Emergency Department pharmacist capacity to oversee allergy documentation and train clinical staff.
Verbatim wording from the response “• Emergency Department specific interventions:” Source location Response from Royal Wolverhampton NHS Trust
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Concerns raised 1
Failure of allergy information to automatically cross-populate between records View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Glennis CONNELLY · Prevention of Future Deaths report
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Report summary
Glennis CONNELLY died at home on 11 November 2022 from end-stage renal failure due to tubulo-interstitial nephritis caused by tazocin, despite a previously identified allergy to the drug. The principal concerns were that this allergy was not recorded in the hospital records at Queens Hospital Burton upon Trent and that electronic patient records across the same trust did not automatically share allergy information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of allergy information to automatically cross-populate between records
Wider context from the report “Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records. Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital, "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020.
” Source location Glennis CONNELLY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the unified electronic patient record across Trust sites, with staged rollout underway and allergy functionality planned for the first phase.
Verbatim wording from the response “Whilst the incident was multifactorial, the unification of the EPR systems is something the Trust is working hard to remedy. As noted, the Trust currently has two enterprise wide systems which include all patient administrative and clinical functionality, appointments, waiting lists, test results, medications, emergency care, maternity and clinical noting.” Source location Response from Derby and Burton NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a multidisciplinary allergy working group to ensure robust systems for managing allergies and alerts.
Verbatim wording from the response “4. Setting up an allergy working group” Source location Response from Derby and Burton NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot extend an existing EPR across all sites because of contractual, technical, support-life and specialist-function constraints.
Verbatim wording from the response “Implementing an entirely new system is not a small undertaking. It is important to get this right for the five hospital sites now and into the future. These EPR systems are not created by the Trust, but rather bought under contracting arrangements with their associated contractual periods, support and shelf life. As was heard at inquest, it has not been possible to extend one of the existing systems to the whole site as they need to function effectively across all specialisms. In the case of one system it is reaching the end of its support life. Any system has to be then integrated into the wider Trust in a safe way, operating alongside our other systems.” Source location Response from Derby and Burton NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Care Quality Commission will assess the incident and determine whether further regulatory action is needed.
Verbatim wording from the response “Where there is any death or serious injury at a provider or service registered by the CQC, the CQC will consider this in line with their specific incident guidance to identify if a patient has suffered avoidable harm or they were placed at significant risk of avoidable harm. This includes when there are issues relating to digital systems, and a specific incident review would consider the role of the system, as well as the registered providers involved.” Source location Response from DHSC
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How this respondent position was interpreted
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PFD Monitor interpretation The University Hospitals of Derby and Burton NHS Foundation Trust will address specific local actions in its separate response.
Verbatim wording from the response “I understand that the University Hospitals of Derby and Burton NHS Foundation Trust will be separately responding to the report and commenting on specific local action in their response.” Source location Response from DHSC
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20 Mar 2022 Mr. Donald Vernon Compton · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to record antibiotic allergies using the relevant drug and constituent-drug names View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Mr. Donald Vernon Compton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Donald Vernon Compton, aged 87, was admitted to hospital after developing Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Covid-19, and died on 14 February 2021. The principal concerns were prescribing and dispensing errors involving Co-trimoxazole despite a known trimethoprim allergy, including failures by hospital staff and a GP to identify the risk. A separate medication error involving excessive amiodarone dosing was also identified.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record antibiotic allergies using the relevant drug and constituent-drug names
Wider context from the report “Prescribing and dispensing errors
1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies;
2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim .
3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised.
4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs.
5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days.
” Source location Mr. Donald Vernon Compton · Prevention of Future Deaths report
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24 Nov 2020 Mrs Ann Patricia Ellen Schuetz · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Lack of allergy-recording functionality in the CAMIS system View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Mrs Ann Patricia Ellen Schuetz · Prevention of Future Deaths report
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Report summary
Mrs Ann Patricia Ellen Schuetz died at Northampton General Hospital on 26 June 2018 following an allergic reaction to Ramipril. The report identifies concerns that her known allergy was not recorded across relevant electronic systems, which allowed Ramipril to be restarted and continued to be prescribed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of allergy-recording functionality in the CAMIS system
Wider context from the report “In the present case, the allergy was not recorded in the appropriate places in the relevant electronic systems. A contributing factor was that that primary and secondary care have a number of different electronic systems in place to manage patient medical information including:-
1. Symphony – Emergency Department system
2. EDN – Electronic Discharge Notification system
3. ePMA – Electronic prescribing system
4. SystemOne – Electronic GP documentation system
5. CAMIS – Overview system which holds such details as ID and all attendances including outpatient
One of the root causes according to the Trust’s Investigation report was “the fact that the electronic patient systems used in primary and secondary care did not have the ability to share information and therefore the updated allergy information was required to be inputted manually into each system….”
The Trust is continuing to explore the feasibility of having regional central medical records but it is not known if any other Trusts are doing the same.
The Investigation report also states that “The CAMIS system currently does not have anywhere to record a patient’s allergies . If a change is to be made to the CAMIS system, this would need to be changed nationally”.
” Source location Mrs Ann Patricia Ellen Schuetz · Prevention of Future Deaths report
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24 Apr 2019 Ioannis AVGOUSTI · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Lack of communication of allergy information within the hospital and to patients, families and GPs View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Ioannis AVGOUSTI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of communication of allergy information within the hospital and to patients, families and GPs
Wider context from the report “(1) On the 2nd September 2017 the NICE Guidance for the Diagnosis and Management of Allergy was not followed.
It was suggested to me that following the episode of anaphylaxis on the 27th July 2018 the NICE protocol was followed and therefore lessons had been learned to protect future patients however, I found that that was not the case.
Whilst two Mast Cell Tryptase tests had been carried out and there had been some rather sporadic marking of a possibility of allergy in some of the hospital documentation, there had been no proper communication either immediately following the incident or later on within the hospital itself nor to the GP nor to Mr. Avgousti himself or his family . This was simply not good enough.
” Source location Ioannis AVGOUSTI · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement redesigned prescription charts displaying medication, reaction and allergy-safety decision information.
Verbatim wording from the response “████████ Head of Nursing for Quality Improvement has undertaken work in conjunction with the Pharmacy team to ensure that the Trust is fully compliant with these NICE guidelines. ████████ has confirmed that the Trust is currently compliant with most of the guidelines and has produced an action plan for the remaining guidelines. This includes a tool, to describe reactions and to determine actual allergy status, which has been developed and this tool will be incorporated into the new design of the Trust’s Prescription chart. The next print run of our newly designed Prescription charts will include:” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
Verbatim wording from the response “All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
Verbatim wording from the response “We have undertaken extensive investigation into the use of red allergy wrist bands, led by the Head of Nursing - Quality Improvement. We have conducted three audits of the appropriate use of red wristbands since January 2019 and there has been 10% improvement on compliance. In addition, our Acute Admissions Unit and Emergency Department are trialing a single coloured wristband system whereby if a patient has an allergy, they will only wear a red wristband with their details on it, and not an additional white wristband. The aim of this trial is to see if it reduces the risk of the red wristband not being seen when checking patients’ details prior to medication administration and our patients like Mr Avgousti who I gather did not like wearing multiple wristbands and would sometimes pull them off, being more comfortable and reducing the risk of removal.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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1 Sep 2017 Mohammad Ismaeel Ashraf · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Unsafe and unreliable lanyard identification of children’s food allergies View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Mohammad Ismaeel Ashraf · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe and unreliable lanyard identification of children’s food allergies
Wider context from the report “4. As an interim measure lanyards had been used to try and identify which food children were allergic to when buying their lunch. The Inquest heard how some lanyards were not accurate and lanyards themselves are not as safe as they may be amended or worn by a different pupil .
” Source location Mohammad Ismaeel Ashraf · Prevention of Future Deaths report
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6 Jun 2017 Joyce Violet Rumming · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Failure of software systems to communicate allergy markers to prescribing clinicians View source
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Joyce Violet Rumming · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joyce Violet Rumming attended the Accident and Emergency Department on 11 December 2016 and was given Amoxicillin and Clarithromycin at 01.45 on 12 December 2016; she died just over half an hour later. The stated cause of death was respiratory failure, and the report says this did not appear to be related to an allergic reaction to Amoxicillin. The principal concern was that information about her recorded Amoxicillin allergy was not effectively communicated between systems and staff, resulting in the antibiotic being administered shortly before her death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of software systems to communicate allergy markers to prescribing clinicians
Wider context from the report “The Route Cause Analysis in relation to items (bullet points) under contributory factors documents a number of areas that give rise for concern. It essentially amounts to right hand not communicating with the left hand in that for example unless a Doctor looks in a specific location due to issues as regards the communication between various software packages that the existence of an allergic marker could be missed as was the situation in relation to Joyce's case.
” Source location Joyce Violet Rumming · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a new electronic clinical note that includes patient allergies.
Verbatim wording from the response “Action Two – Review of documentation of allergies
The majority of documentation in the Emergency Department is electronic. On the electronic patient record system there is an alert section where drug allergies are to be noted. The alert notification tab is then flagged red on the patient’s home page.” Source location 2017-0182-Response-by-Great-Western-Hospital-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore the IT infrastructure interface between the electronic medication and patient record systems.
Verbatim wording from the response “Action Three – Explore the interface between IT systems
The IT infrastructure did not and still does not support sharing of information between the electronic patient medication system and the electronic patient record system. Actions two and four are to bridge this gap and ensure patient safety.” Source location 2017-0182-Response-by-Great-Western-Hospital-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Migrate the Emergency Department onto the Trust-wide server to improve access to electronic medication records.
Verbatim wording from the response “In addition to this, the Emergency Department are being migrated onto the same server which the rest of the Trust uses. This will make it easier for Emergency Department staff to have access to the electronic patient medication record to look up any allergies and with the potential to prescribe medication using this system.” Source location 2017-0182-Response-by-Great-Western-Hospital-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The electronic handover system cannot be tailored to place key information, such as allergies, at the top for individual organisations.
Verbatim wording from the response “The Clinical Risk team had liaised with the local ambulance trust to see whether any changes can be made to the electronic system so that key information, such as allergies, is at the top of the handover document. Our local ambulance trust works with many acute hospitals in the South West region. We have been advised that it is not possible to make” Source location 2017-0182-Response-by-Great-Western-Hospital-NHS-Trust
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29 Jun 2016 Peter Arthur Rowe · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to assess the reliability of negative allergy histories from patients or accompanying persons View source Failure to preserve documented penicillin and aspirin allergy information on the inpatient prescription and administration record View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Peter Arthur Rowe · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Arthur Rowe was administered the penicillin-based antibiotic co-amoxiclav despite a GP referral letter recording a penicillin allergy. He developed a worsening rash, was admitted to hospital with toxic epidermal necrolysis, and died on 8 February 2016 following deterioration. Concerns included the deletion of recorded allergy information and reliance on allergy answers despite Mr Rowe’s poor memory and his wife’s lack of knowledge of his allergy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess the reliability of negative allergy histories from patients or accompanying persons
Wider context from the report “3. On the evidence heard at the Inquest Mr Rowe suffered from very poor memory following his stroke in 1993. In the premises I am concerned that negative answers to questions regarding any allergies stated to have been put to both Mr Rowe and ████████ were accepted at face value when,
a) Mr Rowe suffered from significant memory loss and decreased cognitive function , and
b) When ████████ would not necessarily have known of her husband’s allergy (and indeed did not) .
” Source location Peter Arthur Rowe · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to preserve documented penicillin and aspirin allergy information on the inpatient prescription and administration record
Wider context from the report “2. The fact of the GPs referral letter stating an allergy to both penicillin and aspirin appears to have been transferred on to the Adult Inpatient Prescription and Administration record and then deleted , albeit it is not clear by whom and when.
” Source location Peter Arthur Rowe · Prevention of Future Deaths report
Open source report
7 May 2015 Mrs. Evelyn KENNEDY · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to provide allergy wristbands for patients with known allergies View source
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide allergy wristbands for patients with known allergies
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Source location Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
Open source report
4 Jun 2014 John William Day · Prevention of Future Deaths report Isle of Wight
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Concerns raised 1
Lack of reliable access to patients’ allergy information by out-of-hours doctors View source
Linked responses
Beacon Isle of Wight Clinical Commissioning Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Isle of Wight Clinical Commissioning Group
Develop a system-wide IT strategy to improve access to integrated health records for out-of-hours clinicians.
View source
Beacon
Remind all out-of-hours GPs to seek Vision 360 access when clinically indicated.
View source
Beacon
Continue pressing for IT-system improvements enabling mobile access to patients’ clinical records.
View source
Beacon
Integrate the Adastra out-of-hours system into the overarching hospital ISIS system.
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AI-generated summary
John William Day · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John William Day, who had COPD, heart failure and respiratory difficulties, was found dead on 6 April 2014 while attached to his oxygen supply. An out-of-hours doctor prescribed Co-Amoxiclav after being unable to access Mr Day’s medical records, although he had a known allergy to the drug; the report states that the medication did not cause his death. The principal concern was that out-of-hours doctors could not access patients’ allergy information in every case.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of reliable access to patients’ allergy information by out-of-hours doctors
Wider context from the report “(1) During the course of my investigation, I heard live evidence from ████████ who was the out-of-hours doctor who visited Mr Day. He told me that he did not have access to the ████████ medical records and that this was a common situation . He said that he had asked Mr Day if he had any allergies to medication, and Mr Day replied that he did not have any such allergies. Whilst Mr Day appeared to have capacity, the information which he gave to ████████ was incorrect, and as a consequence, ████████ prescribed Co-Amoxiclav to Mr Day.
(2) In this case, the patient did not die as a result of the medication which was prescribed, but if the patient had died, an inquest would have inevitably resulted. Moreover, the patient had capacity to give an (incorrect) answer, but if the patient lacked capacity to do so, I am concerned that the out-of-hours doctor has no way of verifying the appropriateness of the medication which he wishes to prescribe . Accordingly I am concerned that there is not a way in which out-of-hours doctors can access the “Allergies” section of a patient’s medical notes in every case . As I understand it, even if a patient opts out of the NHS Spine, the information about allergies should still be available to any medical personnel who consult the database.
” Source location John William Day · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a system-wide IT strategy to improve access to integrated health records for out-of-hours clinicians.
Verbatim wording from the response “The Island CCG, along with all other CCGs, is developing a system-wide IT strategy. The aim is to move towards a universal, integrated and readily accessible health care record. This would have considerable benefits to delivery of care in a range of ways of which out of hours access is only one. Frustratingly the practical problems to progress this are considerable and wide ranging. As ████████ explains – the Island is making significant advances with the introduction of an overarching system [ISIS] but we have a long way to go before there is a fully operational shared information system.” Source location 2014-0251-Response-by-Isle-of-Wight-Clinical-Commissioning-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind all out-of-hours GPs to seek Vision 360 access when clinically indicated.
Verbatim wording from the response “1. Reminder sent to all out of hours GPs to consider trying to get access to Vision 360 if clinically indicated.” Source location 2014-0251-Response-by-Beacon-Health-Centre
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue pressing for IT-system improvements enabling mobile access to patients’ clinical records.
Verbatim wording from the response “2. To continue to press for improvements in the IT systems to be able to deliver mobile access to patients clinical record.” Source location 2014-0251-Response-by-Beacon-Health-Centre
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate the Adastra out-of-hours system into the overarching hospital ISIS system.
Verbatim wording from the response “There is no integrated health care record system in the UK that we could adopt that would deliver a comprehensive and mobile health care record across all systems but we are leading the way on the development of that integration on the island. The Beacon out of hours service is working closely primary care, the ambulance service and secondary care. We have already integrated the Adastra system into the overarching hospital system ISIS. Better links between this and the primary care system (Vision) are limited by the unreliability of Vision 360 which is a problem nationally and not within our control. it is more likely to be resolved by a change it the islands primary care system.” Source location 2014-0251-Response-by-Beacon-Health-Centre
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Technical, consent and information-governance limitations prevent routine out-of-hours access to patient records.
Verbatim wording from the response “As chair of the organisation responsible for commissioning out of hours GP services and as a practising GP I am familiar with the severe limitations of the current information systems available to out of hours doctors. There have been various attempts to improve clinical information sharing through IT developments, nationally, regionally and locally. Results have been variable and often of limited functionality. In particular difficulties relating to consent and information governance have resulted in incomplete access. The technical problems mean that even the system on the Island [Vision 360] is not easy to access and not always reliable.” Source location 2014-0251-Response-by-Isle-of-Wight-Clinical-Commissioning-Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Better links between hospital and primary care records cannot currently be delivered because Vision 360 is unreliable and outside the respondent’s control.
Verbatim wording from the response “There is no integrated health care record system in the UK that we could adopt that would deliver a comprehensive and mobile health care record across all systems but we are leading the way on the development of that integration on the island. The Beacon out of hours service is working closely primary care, the ambulance service and secondary care. We have already integrated the Adastra system into the overarching hospital system ISIS. Better links between this and the primary care system (Vision) are limited by the unreliability of Vision 360 which is a problem nationally and not within our control. it is more likely to be resolved by a change it the islands primary care system.” Source location 2014-0251-Response-by-Beacon-Health-Centre
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resolving Vision 360’s unreliability is more likely to require a change to the island’s primary care system.
Verbatim wording from the response “There is no integrated health care record system in the UK that we could adopt that would deliver a comprehensive and mobile health care record across all systems but we are leading the way on the development of that integration on the island. The Beacon out of hours service is working closely primary care, the ambulance service and secondary care. We have already integrated the Adastra system into the overarching hospital system ISIS. Better links between this and the primary care system (Vision) are limited by the unreliability of Vision 360 which is a problem nationally and not within our control. it is more likely to be resolved by a change it the islands primary care system.” Source location 2014-0251-Response-by-Beacon-Health-Centre
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.