PFD report

Sharon Anne ROBINSON · Prevention of Future Deaths report

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Issued 16 Nov 2021•West Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to act on patients' antibiotic sensitivity
    Part of recurring concern: Unsafe medication prescribing
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Discussed the case with senior clinical leaders across the Trust and wider regional healthcare organisations to promote consistent allergy-risk decision-making.

    Stated by Airedale NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2021.
  2. Action

    Align the antimicrobial approach across Bradford Teaching Hospitals and Airedale Hospitals, including revising the Antimicrobial Policy using evidence-based practice.

    Stated by Airedale NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2021.
  3. Action

    Discussed the case through the Yorkshire and Humber Antimicrobial Pharmacists Network to disseminate learning on safe prescribing with recorded allergies.

    Stated by Airedale NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    A documented antibiotic allergy is not necessarily ignored when clinicians investigate its history and make an evidence-based, clinically considered prescribing decision.

    Stated by Airedale NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to act on patients' antibiotic sensitivity

Wider context from the report

“There is a concern that when a patient may have a sensitive to anti-biotic despite the low risk, this will be ignored and anti-biotic be given in any event. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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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

Discussed the case with senior clinical leaders across the Trust and wider regional healthcare organisations to promote consistent allergy-risk decision-making.

Verbatim wording from the response

“• Case discussed at the Senior Medical Leadership Group meeting. This includes all Clinical Directors and Divisional Medical Directors within Airedale NHS Foundation Trust.”

Source location

2021-0385-Response-from-Airedale-General-Hospital_Published
Page 2 · response
Published 19 November 2021

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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

Align the antimicrobial approach across Bradford Teaching Hospitals and Airedale Hospitals, including revising the Antimicrobial Policy using evidence-based practice.

Verbatim wording from the response

“• Chief Pharmacist and Executive Medical Director are working to align the approach for Bradford Teaching Hospitals and Airedale Hospitals, which will be overseen by the Drug and Therapeutics Committee. This includes revision of the Antimicrobial Policy – to build in best evidence-based practice with experts to implement safe patient care.”

Source location

2021-0385-Response-from-Airedale-General-Hospital_Published
Page 2 · response
Published 19 November 2021

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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

Discussed the case through the Yorkshire and Humber Antimicrobial Pharmacists Network to disseminate learning on safe prescribing with recorded allergies.

Verbatim wording from the response

“• The Trust Antimicrobial Pharmacist has discussed this case at the Yorkshire and Humber Antimicrobial Pharmacists Network.”

Source location

2021-0385-Response-from-Airedale-General-Hospital_Published
Page 2 · response
Published 19 November 2021

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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

A documented antibiotic allergy is not necessarily ignored when clinicians investigate its history and make an evidence-based, clinically considered prescribing decision.

Verbatim wording from the response

“I would then like to address the suggestion that a patient’s sensitivity to an antibiotic would be ‘ignored’ and an antibiotic given in any event. In the case of Mrs Robinson, the Trust’s evidence given at inquest was that Mrs Robinson’s recorded allergy to Penicillin was not ‘ignored’. It was carefully considered when the treating clinician exercised their clinical decision making around whether or not it would be appropriate and safe to administer Amoxicillin (Penicillin-based antibiotic) for a Lower Respiratory Tract Infection (‘LRTI’) in January 2019. The Trust’s evidence was that, before deciding to prescribe Amoxicillin, the patient had reported to clinical staff that, notwithstanding the ‘allergy alert’ on her file, she”

Source location

2021-0385-Response-from-Airedale-General-Hospital_Published
Page 1 · response
Published 19 November 2021

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Continue engaging wider healthcare providers to understand effective allergy-risk management and promote visibility of the Coroner’s recommendations.

    Stated by Airedale NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2021.

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 engaging wider healthcare providers to understand effective allergy-risk management and promote visibility of the Coroner’s recommendations.

Verbatim wording from the response

“The Trust is, therefore, seeking ongoing wider engagement with other healthcare providers to understand how this risk is effectively managed in those organisations and ensuring that HM Coroner’s recommendations are visible in their own organisations.”

Source location

2021-0385-Response-from-Airedale-General-Hospital_Published
Page 3 · response
Published 19 November 2021

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026