24 Sep 2020 Eileen Brindley · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Failure to conduct a consultation before issuing prescriptions View source Failure to avoid prescribing penicillin type antibiotics despite recorded adverse reactions View source Insufficient highlighting of adverse medical history entries View source Failure to note recorded adverse reactions before prescribing View source Failure to explain prescribing decisions despite recorded adverse reactions View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Complete educational updates on prescription errors, prescribing, remote consultations, allergy and anaphylaxis, and pandemic-related change.
Stated completedThe respondent said that this action was complete when they made their response on 7 January 2021. View source
Action
Review and update the allergy-recording policy to require consistent coding, visible allergy status, reaction severity and reaction descriptions, then provide it to staff.
Stated completedThe respondent said that this action was complete when they made their response on 7 January 2021. View source
Action
Require clinicians to check documented allergies in the clinical record summary before prescribing.
Stated completedThe respondent said that this action was complete when they made their response on 7 January 2021. View source
Action
Make a face-to-face or remote consultation mandatory before prescribing medication, involving the patient or an appropriate carer or healthcare professional.
Stated completedThe respondent said that this action was complete when they made their response on 7 January 2021. View source
Action
Instruct clinicians not to prescribe medication carrying an electronic allergy alert.
Stated completedThe respondent said that this action was complete when they made their response on 7 January 2021. View source
Action
Remind clinicians to make clear and detailed patient-record notes.
Stated completedThe respondent said that this action was complete when they made their response on 7 January 2021. View source
Action
Audit all electronically recorded allergic reactions and add available details distinguishing allergy or side effect, timing, severity and symptoms.
Stated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021. View source
Action
Instruct clinicians and administrative staff to code prescription alerts accurately.
Stated completedThe respondent said that this action was complete when they made their response on 7 January 2021. View source See 5 more actions
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AI-generated summary
Eileen Brindley · 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
Eileen Brindley, aged 97, was admitted to New Cross Hospital on 28 August 2020 after being found struggling to breathe and died shortly afterwards from anaphylaxis. The concerns included prescribing a penicillin-type antibiotic despite a recorded adverse reaction to Flucloxacillin, without evidence that the prescribing clinician had noted the reaction or explained the prescription, and insufficiently highlighted medical-record entries.
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. The report was sent to Tettenhall Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a consultation before issuing prescriptions
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted;
3) The prescription was issued with any consultation either in person or over the telephone ;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tettenhall Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid prescribing penicillin type antibiotics despite recorded adverse reactions
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin ;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted;
3) The prescription was issued with any consultation either in person or over the telephone;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tettenhall Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Insufficient highlighting of adverse medical history entries
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted;
3) The prescription was issued with any consultation either in person or over the telephone;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tettenhall Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to note recorded adverse reactions before prescribing
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted;
3) The prescription was issued with any consultation either in person or over the telephone;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tettenhall Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to explain prescribing decisions despite recorded adverse reactions
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted ;
3) The prescription was issued with any consultation either in person or over the telephone;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased;
” 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 Complete educational updates on prescription errors, prescribing, remote consultations, allergy and anaphylaxis, and pandemic-related change.
Verbatim wording from the response “11) ████████ has completed various educational updates including a MIMS course on avoiding prescription errors, RCGP course on prescribing, MDU course on remote consultation skills, MIMS course on allergy and anaphylaxis and BMJ course on tips for coping with change during a pandemic.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
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 Review and update the allergy-recording policy to require consistent coding, visible allergy status, reaction severity and reaction descriptions, then provide it to staff.
Verbatim wording from the response “4) We have reviewed how allergies are recorded in the medical records. Our discussions focused on the issues generated by this case but included a broader review of coding of all allergies. Following those discussions we have updated our policy ‘Recording Allergies in Patient Records’ and this has been provided to all staff in hard copy and is accessible on a shared computer drive. The key points are:” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
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 Require clinicians to check documented allergies in the clinical record summary before prescribing.
Verbatim wording from the response “8) All clinicians have been reminded to specifically check allergies documented in the clinical record summary before prescribing for any patient.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
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 Make a face-to-face or remote consultation mandatory before prescribing medication, involving the patient or an appropriate carer or healthcare professional.
Verbatim wording from the response “7) It is now mandatory to ensure a face to face or remote consultation has taken place before prescribing any medication, ideally with the patient themselves but where this is not possible then with their carer or another healthcare professional involved in their care.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
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 Instruct clinicians not to prescribe medication carrying an electronic allergy alert.
Verbatim wording from the response “9) Clinicians have been instructed never to prescribe any medication which has an electronic alert indicating the patient has an allergy.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
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 clinicians to make clear and detailed patient-record notes.
Verbatim wording from the response “13) Reminder has been made to all clinicians always to make clear and detailed notes in the patient records.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
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 Audit all electronically recorded allergic reactions and add available details distinguishing allergy or side effect, timing, severity and symptoms.
Verbatim wording from the response “6) The practice is carrying out an extensive audit of all allergic reactions recorded on the electronic record system. This audit is being conducted by one of the administration team with oversight from the Practice Manager. All allergies and side effects are recorded as an ‘adverse reaction’ as this is the only alert code available. However this audit is conducting a review to make sure that wherever possible additional notes are made giving a wider description including, where known, whether the reaction is allergy/side effect, new/historical, mild/severe and symptoms of the reaction such as a rash or breathing difficulties.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
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 Instruct clinicians and administrative staff to code prescription alerts accurately.
Verbatim wording from the response “10) All clinicians and administrative staff have been instructed to accurately code any prescription alerts.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations