Jennifer Susan BIRCH · Prevention of Future Deaths report

On 15 April 2025 I commenced an investigation into the death of Jennifer Susan BIRCH aged 27. The investigation concluded at the end of the inquest on 20 May 2026.
The conclusion of the inquest was that:

Jen died as a result of a rare anaphylactic response to teicoplanin.

Jennifer Susan Birch died on 11 April 2025, at the Queens Medical Centre, Nottingham, as a result of an hypoxic brain injury, sustained during a period of anaphylaxis in response to the administration of intravenous prophylactic antibiotic, teicoplanin, in the peri-operative period of an elective procedure performed on 8 April 2025.

During the peri-operative anaesthetic emergency, a 2222 call was not put out, contrary to local guidance. While this probably led to some omissions in the care that could have been provided to Jen, it has not been possible to determine whether such omissions have more than minimally contributed to her death.

1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour

The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.

My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart.

This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).

The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.

2. (ICB) Roll out of the Penicillin Allergy De-Labelling Pathway

Teicoplanin carries a rare but recognised risk of severe anaphylaxis and reaction occurring in an estimated 0.1-1% of cases. Teicoplanin is often used as an alternative to penicillin for patients who report penicillin allergy. The risk of serious complications is greater in teicoplanin than many other forms of antibiotic (NAP6). It has been described as “an emerging problem in the anaesthetic allergy clinic” (British Journal of Anaesthesia, 2015).

Jen was administered teicoplanin in the peri-operative period because the recommended antibiotic for her elective procedure, Flucloxacillin, is from the same antibiotic family as penicillin, and Jen’s medical records reported an allergy to penicillin in the form of a rash as a baby.

The use of teicoplanin in this case was entirely appropriate given Jen’s allergy warning, but it did expose her to a risk of severe anaphylaxis, which materialised and caused her death. In the months following Jen’s death, some Trusts have rolled out an inpatient initiative to seek to de-label penicillin allergy from patient medical records where risk stratification determines that the patient does not have a true allergy to penicillin. The SPACE study established that up to 10% of the population carries documented penicillin allergy but over 90% of these are inaccurate. False labels have been shown to increase antibiotic resistance, higher surgical site infections, longer hospital stays, as well as exposing patients to unnecessary complications associated with second-line antibiotics.

One local Trust, Doncaster and Bassetlaw NHS Trust, has already rolled out an inpatient PADL pathway. The SPACE study proved it is clinically safe and effective for non-allergy healthcare professionals to use approved risk stratification and direct oral penicillin challenges for low-risk patients, ensuring the burden for this pathway does not impact on the often-small secondary care allergy service.

Does the ICB plan to commission this pathway across all local Trusts? At present, NUH does not offer this pathway.