1 Aug 2025 Margaret Ann MCNAUGHTON · Prevention of Future Deaths report Black Country
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Concerns raised 3 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 Failure to demonstrate compliance with the medication-error management policy View source
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to the Royal Wolverhampton NHS Trust; that does not assign responsibility.
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.
” 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 the Royal Wolverhampton NHS Trust; that does not assign responsibility.
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.
” 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 the Royal Wolverhampton NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate compliance with the medication-error management policy
Wider context from the report “13. After reviewing the Policies provided to me, I also noted in The Trusts Management of Medication Errors Policy it defines level 1 and level 2 errors. I do not know what Level the incident concerning Mrs McNaughton was graded as but a level 2 error includes ‘Errors resulting in actual patient harm i.e. any physical effect to a patient that is directly a result of a medication error’. The incident report that I have been provided with only refers to an ‘amber’ incident. I understand the prescriber concerned in this case was a locum doctor and the policy states; In the event of a locum doctor making an error the WMI will forward the report to both HR and the clinical lead for the doctor’s specialty’. The Policy also states ‘The doctor will be counselled by their educational supervisor or clinical lead at the time of the incident who will require them to reflect on their practice. Suspension of a doctor from prescribing or administration of medicines will only occur if the doctor, their educational supervisor or clinical lead assesses that patients will be put at risk if the individual continues to prescribe. If necessary any further training will be arranged through the relevant clinical supervisor or clinical lead’.
14. I was not provided with a statement from the prescribing clinician involved in the incident referred to here although I was informed that the locum Doctor concerned had left the Trust. I have not been reassured by the Trust that they followed their own policy in terms of how this medication error was dealt with at the time and therefore I am concerned that this presents a risk to patient safety at this time .
” Open source report
3 Aug 2022 Mrs Rita Flynn · Prevention of Future Deaths report Black Country
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Concerns raised 1 Failure to await blood test results before discharge View source
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AI-generated summary
Mrs Rita Flynn · 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 Rita Flynn became ill with flu-like symptoms and was assessed by her GP and New Cross Hospital. Her condition deteriorated, with shortness of breath and haemoptysis, and she was discharged home before blood-test results indicating infection were available; she died at home on 4 February 2022. The inquest found that she died after complications arising from a lung abscess, and the concern identified was that it would have been best practice to wait for the blood-test results before discharge.
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× 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 the Royal Wolverhampton NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to await blood test results before discharge
Wider context from the report “1. Evidence emerged during the inquest that there were clear indicators of an infection and before being discharged home by the hospital, it would have been best practice to wait for the blood tests results .
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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 proactive blood-result review into postgraduate induction training and disseminate the requirement to postgraduate staff.
Verbatim wording from the response “There has been an agreed plan within ED to incorporate within the training portfolio of postgraduate doctors, the importance of an initiative-taking and proactive review of blood results prior to discharge of patients. Such training will be delivered at induction level.” Source location Response from The Royal Wolverhampton
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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 Allocate consultant work-plan time to review blood results in the ICE system within 24 hours.
Verbatim wording from the response “Consultants on duty will be allocated time within their work plan to review blood results in the Clinical Webb Portal - ICE system (system which records all results), to review blood results in a timely manner (within 24 hours).” Source location Response from The Royal Wolverhampton
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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 Use the ED clerking form’s investigations-and-results section to document blood-result review before discharge.
Verbatim wording from the response “An ED clerking document is completed by reviewing staff including Doctors, within the Clerking form a section for investigations and results has been incorporated so that such results and investigations are documented. All Doctors/Clinicians will complete the investigations review section. This will be assurance and used as a checklist criteria to show evidence that results have been reviewed, as well as results being filed at the time they have been seen prior to the discharge of patients.” Source location Response from The Royal Wolverhampton
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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 include the discharge blood-result process in ED policy and guidance.
Verbatim wording from the response “1. To consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection showed.” Source location Response from The Royal Wolverhampton
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30 May 2017 Mrs Sarah Poole · Prevention of Future Deaths report Black Country
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Concerns raised 2 Failure to take previous abnormal ECG results into account during paramedic handover View source Failure to record and endorse the reviewing doctor’s name on ECGs View source
Responses linked to these concerns
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AI-generated summary
Mrs Sarah Poole · 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 Sarah Poole was admitted to hospital with sudden headache and back pain, but an abnormal ECG was incorrectly considered normal and she was discharged home. She was readmitted the following day, diagnosed with an aortic dissection and underwent emergency surgery, but developed complications and died on 5 November 2016. The principal concern was a failure to record and endorse the reviewing doctor’s name and to consider previous abnormal ECG results during handover.
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× 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 the Royal Wolverhampton NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take previous abnormal ECG results into account during paramedic handover
Wider context from the report “1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff .
” 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 the Royal Wolverhampton NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and endorse the reviewing doctor’s name on ECGs
Wider context from the report “1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff.
” 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 Summarise electronic ambulance handover information into one or two sheets and attach it to emergency department documentation.
Verbatim wording from the response “With regards to the ambulance handover there have been problems with the new electronic handover system producing lengthy documents. However, we have now introduced a way of summarising this information into 1 to 2 sheets which will be printed off and attached to the ED patient documentation. To ensure that medical staff review this information we have included in the discharge checklist (shared at the inquest) a statement which will ask the clinician to confirm that they have read the pre-hospital information. The checklist has been agreed by the Senior Team in ED and is in the process of being incorporated electronically into the printed element of ED patient documentation. We cannot confirm at this time the exact implementation date but it will be within the next month, and along with the ECG process we plan to audit the compliance with the discharge checklist on a monthly basis.” Source location 2017-0176-Response-by-The-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 Incorporate a clinician confirmation that pre-hospital information was reviewed into the emergency department discharge documentation.
Verbatim wording from the response “With regards to the ambulance handover there have been problems with the new electronic handover system producing lengthy documents. However, we have now introduced a way of summarising this information into 1 to 2 sheets which will be printed off and attached to the ED patient documentation. To ensure that medical staff review this information we have included in the discharge checklist (shared at the inquest) a statement which will ask the clinician to confirm that they have read the pre-hospital information. The checklist has been agreed by the Senior Team in ED and is in the process of being incorporated electronically into the printed element of ED patient documentation. We cannot confirm at this time the exact implementation date but it will be within the next month, and along with the ECG process we plan to audit the compliance with the discharge checklist on a monthly basis.” Source location 2017-0176-Response-by-The-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 Audit compliance with the emergency department discharge checklist monthly.
Verbatim wording from the response “With regards to the ambulance handover there have been problems with the new electronic handover system producing lengthy documents. However, we have now introduced a way of summarising this information into 1 to 2 sheets which will be printed off and attached to the ED patient documentation. To ensure that medical staff review this information we have included in the discharge checklist (shared at the inquest) a statement which will ask the clinician to confirm that they have read the pre-hospital information. The checklist has been agreed by the Senior Team in ED and is in the process of being incorporated electronically into the printed element of ED patient documentation. We cannot confirm at this time the exact implementation date but it will be within the next month, and along with the ECG process we plan to audit the compliance with the discharge checklist on a monthly basis.” Source location 2017-0176-Response-by-The-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 Require Senior Decision Makers to review and sign off all ECGs, and audit compliance monthly.
Verbatim wording from the response “The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker, i.e. a middle grade Doctor or Consultant.” Source location 2017-0176-Response-by-The-Royal-Wolverhampton-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations