PFD report

Beatrice Florence May DAWKINS · Prevention of Future Deaths report

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Issued 5 Apr 2022•Hampshire, Portsmouth and Southampton

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 raised2

  1. Failure to flag relevant critical care information to clinicians
  2. Failure to make relevant critical care information accessible to clinicians
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.5

  1. Action

    Change the discharge summary template to include an option for recording new allergies in the GP Actions section.

    Stated by PHU TrustStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
  2. Action

    Support electronic Transfer of Care Around Medicines information sharing with community pharmacies through PharmOutcomes.

    Stated by PHU TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2022.
  3. Action

    Use EPMA to populate medicines and allergy information automatically in electronic inpatient discharge summaries.

    Stated by PHU TrustStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.

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

  1. Position

    The possibility of recurrence cannot be completely eradicated because patient information is complex and recording remains subject to occasional human error.

    Stated by PHU TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 flag relevant critical care information to clinicians

Wider context from the report

“The deceased's medical notes contained at least seven entries indicating the deceased had a sensitivity to chloramphenicol, the first such entry being recorded in 1997. Those medical notes included notes made by the Queen Alexandra Hospital, Portsmouth in which the deceased's recorded allergies included chloramphenicol. Evidence was adduced that had the clinicians involved in the care and treatment of the deceased in September 2020 had knowledge of those notes and/or the deceased's sensitivity to chloramphenicol had been flagged in the medical records during the deceased's September 2020 admission chloramphenicol would not have been prescribed to the deceased. My concern is that relevant, critical information relating to the care and treatment of the deceased was in existence but was not accessible nor flagged up to those involved in the care and treatment of the deceased. In the absence of a process where relevant, critical information is not accessible nor flagged up to clinicians there continues to be a future risk to life. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 make relevant critical care information accessible to clinicians

Wider context from the report

“The deceased's medical notes contained at least seven entries indicating the deceased had a sensitivity to chloramphenicol, the first such entry being recorded in 1997. Those medical notes included notes made by the Queen Alexandra Hospital, Portsmouth in which the deceased's recorded allergies included chloramphenicol. Evidence was adduced that had the clinicians involved in the care and treatment of the deceased in September 2020 had knowledge of those notes and/or the deceased's sensitivity to chloramphenicol had been flagged in the medical records during the deceased's September 2020 admission chloramphenicol would not have been prescribed to the deceased. My concern is that relevant, critical information relating to the care and treatment of the deceased was in existence but was not accessible nor flagged up to those involved in the care and treatment of the deceased. In the absence of a process where relevant, critical information is not accessible nor flagged up to clinicians there continues to be a future risk to life. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Change the discharge summary template to include an option for recording new allergies in the GP Actions section.

Verbatim wording from the response

“Inpatient discharge summaries are sent electronically to GP practices. With the introduction of EPMA the medicines component of those summaries will now be populated by the EPMA system to improve their accuracy. For medicines this will require the prescriber to select the medication to appear on the discharge summary, for allergies this will pull through automatically. It is already recommended to our teams that any new allergies should be flagged in the GP Actions section of the discharge summary to ensure that they are translated effectively into the primary care patient records. To further reinforce this, we will be making a change to the discharge summary template with the support of the DigiMeds team (the team supporting the introduction of EPMA into the Trust), to include this as an option. We will also be looking to remove the ‘no action’ option to promote clear recording.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 2 · response
Published 26 April 2022

Open published response

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

Support electronic Transfer of Care Around Medicines information sharing with community pharmacies through PharmOutcomes.

Verbatim wording from the response

“for Quality and Innovation incentive (CQUIN) for 2022-23 is currently being deployed to promote the Transfer of Care Around Medicines (TCAM). TCAM requires the pharmacy team within Acute Hospital Trusts to communicate any high-risk patients to their community pharmacy, for example if a new drug allergy has been identified. This information will be transmitted electronically and stored on the records of the community pharmacy for that patient. The presence of this information held within the database of the community pharmacy will increase the opportunity for the GP practice to obtain that information and record it on their own systems. PHU Trust will be supporting this transfer of information using the PharmOutcomes platform.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 3 · response
Published 26 April 2022

Open published response

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

Use EPMA to populate medicines and allergy information automatically in electronic inpatient discharge summaries.

Verbatim wording from the response

“Inpatient discharge summaries are sent electronically to GP practices. With the introduction of EPMA the medicines component of those summaries will now be populated by the EPMA system to improve their accuracy. For medicines this will require the prescriber to select the medication to appear on the discharge summary, for allergies this will pull through automatically. It is already recommended to our teams that any new allergies should be flagged in the GP Actions section of the discharge summary to ensure that they are translated effectively into the primary care patient records. To further reinforce this, we will be making a change to the discharge summary template with the support of the DigiMeds team (the team supporting the introduction of EPMA into the Trust), to include this as an option. We will also be looking to remove the ‘no action’ option to promote clear recording.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 2 · response
Published 26 April 2022

Open published response

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

Share learning from the case with local GP practices to reinforce cross-referencing hospital-reported allergies against primary care records at discharge.

Verbatim wording from the response

“A key requirement to prevent further cases of this type, is to work with primary care to ensure that the GP records can be as complete as possible in relation to Adverse Drug Reactions (ADR) including allergies. To support that in Portsmouth and Southeast Hampshire (PSEH), we will share the learning from this case with local GP practices to reinforce the need for allergies reported by the hospital to be cross referenced with Primary Care records when patients are discharged. In the case of Mrs Dawkins, the allergy reported by the patient during previous hospital appointments was included within written correspondence to the GP but was still not added to the GP record.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 3 · response
Published 26 April 2022

Open published response

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 the EPMA rollout across Trust wards and Emergency Department, retaining allergy information and prominently flagging allergies during prescribing and administration.

Verbatim wording from the response

“As was described in the evidence adduced at the inquest, an Electronic Prescribing and Medicines Administration (EPMA) system is currently being rolled out to every inpatient ward across the Trust and the Emergency Department. It has already been rolled out across medicine and will be extended to all wards across the Trust by the end of 2022. This system will retain information regarding any previous documented allergies or drug sensitivities and will provide that detail automatically when any new prescription is commenced to support future admissions. There is also a requirement to specify the nature of the allergy at the point it is documented. The data on drug allergies and sensitivities are flagged up prominently whenever the electronic drug chart is being reviewed, when new medicines are being prescribed, and when medicines are being administered by the nursing team.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 2 · response
Published 26 April 2022

Open published response

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 possibility of recurrence cannot be completely eradicated because patient information is complex and recording remains subject to occasional human error.

Verbatim wording from the response

“The initiatives described will significantly reduce the risk of a recurrence of Mrs Dawkins case, both immediately and into the future. Given the number of patients that the hospital cares for each year, the complexity of the information pertaining to them and the fact that the accuracy of its recording is subject to human error on occasions, unfortunately it will not be possible to completely eradicate the possibility of an episode of this type occurring again.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 4 · response
Published 26 April 2022

Open published response

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.2

  1. 1

    Share the developed handheld severe-allergy cards with the Hampshire and Isle of Wight Medication Safety Group as best practice.

    Stated by PHU TrustStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
  2. 2

    Develop and make handheld severe-allergy cards available within the Trust for patients with difficulty remembering or multiple significant allergies.

    Stated by PHU TrustStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Clinicians cannot review every historical electronic and paper record because modern acute healthcare time constraints make this impracticable.

    Stated by PHU TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Share the developed handheld severe-allergy cards with the Hampshire and Isle of Wight Medication Safety Group as best practice.

Verbatim wording from the response

“Handheld severe allergy cards will also be developed and made available within PHU for patients who have difficulties remembering their allergies or who have multiple significant allergies. Upon development, these cards will be shared with the Hampshire and Isle of Wight Medication Safety Group as recommended best practice for wider adoption.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 3 · response
Published 26 April 2022

Open published response

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

Develop and make handheld severe-allergy cards available within the Trust for patients with difficulty remembering or multiple significant allergies.

Verbatim wording from the response

“Handheld severe allergy cards will also be developed and made available within PHU for patients who have difficulties remembering their allergies or who have multiple significant allergies. Upon development, these cards will be shared with the Hampshire and Isle of Wight Medication Safety Group as recommended best practice for wider adoption.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 3 · response
Published 26 April 2022

Open published response

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

Clinicians cannot review every historical electronic and paper record because modern acute healthcare time constraints make this impracticable.

Verbatim wording from the response

“It is not possible for doctors, other prescribers, or the pharmacy team to go through every historical electronic and paper record available for each patient due to the realistic time constraints present for all practitioners in a modern acute healthcare system. Thus, where an allergy has not been transcribed into CHIE or SCR and is not mentioned within recent hospital derived medical correspondence, risk arises of the sort demonstrated in this case.”

Source location

Response from Portsmouth Hospitals NHS Trust
Page 2 · response
Published 26 April 2022

Open published response
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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