Recurring concern

Unreliable recording and communication of patient allergy information

First to latest report 5 Dec 2013 — 1 Aug 2025

Reports that mention this concern
12
Times this concern has been raised
17
Stated actions linked to this concern
15

What this concern includes

Includes failures of controls dedicated to managing patient allergy information across its safety-critical lifecycle, including recording allergy status, accessing or verifying it before treatment, transferring it between clinical systems or services, and communicating it promptly to clinicians, GPs, patients or families; include the anchor's post-anaphylaxis communication failure.

What is not included
  • Excludes food-allergy-specific safety systems, including food-allergy action plans, unless the assertion also concerns the general patient-allergy-information process; the existing food-allergy parent is the more specific boundary where applicable.
  • Excludes generic clinical-record, electronic-system or inter-service communication failures where allergy information is not the material unsafe object.
  • Excludes failures in diagnosis, treatment or referral for allergy or anaphylaxis where allergy information was reliably recorded and communicated.
  • Excludes general medication prescribing or allergy-management deficiencies that do not concern recording, accessing, verifying or communicating patient allergy information.

Reports and published responses 12 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North East Kent

    AI-generated summary

    Nicos Andreas MICHAEL · 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

    Nicos Andreas MICHAEL died in hospital on 1 November 2013 after suffering a cardiac arrest and significant brain injury following an acute anaphylactic reaction to intravenously administered Augmentin. The principal concerns were that allergy information was conflicting or incompletely recorded, a historic hospital record of an Augmentin reaction was not carried forward or passed to the GP, and systems did not reliably make previous allergy information available to treating staff.

    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

    Failure to transfer recorded medication allergy information across subsequent records and to GPs

    Wider context from the report

    “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen). (2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP. (3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate. (4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies. ”

    Source location

    Nicos Andreas MICHAEL · Prevention of Future Deaths report
    Page 2 · concerns

    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 ensure checking of earlier paper records for allergy information

    Wider context from the report

    “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen). (2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP. (3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate. (4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies. ”

    Source location

    Nicos Andreas MICHAEL · Prevention of Future Deaths report
    Page 2 · concerns

    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 ensure compulsory electronic prescribing for allergy checking

    Wider context from the report

    “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen). (2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP. (3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate. (4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies. ”

    Source location

    Nicos Andreas MICHAEL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    The records did not contain a consistently recorded penicillin allergy; staff were aware of the patient's reported allergies.

    Verbatim wording from the response

    “1. There was no consistently recorded allergy to penicillin contained in the healthcare records held by the Trust. Indeed the patient himself did not articulate an allergy to penicillin at his pre-operative assessment; he did state allergies to Ibuprofen and Aspirin and red “known allergy” wristbands were applied from the date of his admission. The staff on ICU and on Kent Ward were all aware of Mr Michael’s reported allergies.”

    Source location

    2014-0168-Response-by-East-Kent-Hospitals-University
    Page 1 · response
    Published 14 April 2014

    Open published response

  2. Plymouth, Torbay and South Devon

    AI-generated summary

    Desmond Roy Statton · 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

    Desmond Roy Statton died after suffering a severe allergic reaction shortly after contrast medium was administered for a CT scan. The report raises concerns that radiographers and clinicians could not access allergy and alert information held on other hospital computer systems, and that nursing staff were not sufficiently aware of the risks associated with chlorhexidine.

    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

    Failure of clinicians to access alerts or allergy information recorded in other hospitals

    Wider context from the report

    “2. Derriford is a tertiary hospital and accepts admissions from other hospitals elsewhere in the South West. Clinicians in Derriford are not able to access information relating to alerts or allergies recorded on the computer programmes in other hospitals. ”

    Source location

    Desmond Roy Statton · Prevention of Future Deaths report
    Page 3 · concerns

    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 of radiographers to access alerts or allergy information across hospital computer programmes

    Wider context from the report

    “1. Radiographers are not able to access information concerning alerts or allergies contained on different computer programmes elsewhere in the Hospital. ”

    Source location

    Desmond Roy Statton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026