Mrs Oriel Vasey · Prevention of Future Deaths report

On 13th August 2025 I commenced an Investigation into the death of Mrs Oriel Vasey, who died in Sunderland on 5th March 2025 aged 88 years. The Investigation concluded at the end of the Inquest on 16th December 2025.

I gave the following narrative conclusion: -

Oriel Vasey died on 5 March 2025 at Sunderland Royal Hospital. She had developed a pressure area on her sacrum which deteriorated and resulted in the development of sepsis. This sepsis was treated at hospital but unfortunately caused Oriel's death.

The medical cause of death was confirmed as: -
Ia. Infected pressure sore
Ib. frailty of old age
II. Alzheimer's dementia

Oriel Vasey was admitted to Regents View Care Home having been detained under s3 of the Mental Health Act and spent a period of time under the care of the Mental Health Trust.

As is routine, at the point a person is eligible for discharge from the Mental Health Act, the relevant Integrated Care Board and the Local Authority, are asked to consider the funding and placement arrangements for that person who is eligible for support under s117 of the Mental Health Act 1983. As part of this process a form is completed by the mental health team which identifies what needs that person has.

In Oriel's case this form had been completed by a nurse, and during the Inquest it became clear that a previous service user's form had been used as the starting point, and unfortunately erroneous information had been left on the form in respect of the allergies. The form in Oriel's case therefore retained a reference to a penicillin allergy which was not the case for Oriel.

During the Inquest, evidence confirmed that this form was intended purely for the allocation of funding and was not intended to form part of the patient's clinical record. However also in evidence was that in Oriel's case the erroneous information from this form had been added into her clinical record and as a result, when infection was identified, penicillin as the first line antibiotic, was ruled out by doctors treating her. This happened on a number of occasions although in Oriel's case I could find no evidence that this would have changed the outcome for her.

Family raised concerns with clinicians that she had previously had penicillin to good effect but the GP was unable to amend the record because this had come from an official source and therefore the risk of amending allergy information on the basis of information from family members was greater than the risk of working on the basis of the allergy information being correct.

1. This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.
2. If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies. That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record.