Marjory Rosina ELLERY · Prevention of Future Deaths report

The inquest into Marjory Rosina Ellery’s death was opened on the 26th February 2013 was resumed on 12th of November 2014.

The Coroner found the cause of death was:

1a – Anaphylactic shock (clopidogrel and dalteparin related)

2 – Ischaemic heart disease due to coronary artery atheroma

The Coroner returned a narrative conclusion:

Marjorie Rosina Ellery died at 05.40 hours on the 16th January 2014 at Frimley Park Hospital following the administration of medication to which she was known to be allergic and which caused anaphylactic shock and subsequently death.

On 15th January 2014 Marjorie Ellery was taken by ambulance to Frimley Park Hospital following her experiencing chest pains. She was seen by a staff nurse and her allergies to medications were noted and placed on red wristbands. Mrs Ellery was examined by an A&E doctor who prescribed Acute Coronary Syndrome Medications (ACS) - two of which Mrs Ellery was known to have an allergic reaction to. One of these medications (Clopidogrel) had been prescribed despite a known allergic reaction in late 2013 when ACS Medications were administered. This was without problem. Dalteparin had not been prescribed at this time and an alternative was used. The Dr handed over the administration of the medications to a staff nurse. The staff nurse told Mrs Ellery she would be given three medications to which she was allergic but which she had been given in the past. The names of the medications were not given to Mrs Ellery and she had only received two of the three in the past. Soon after taking the medication Mrs Ellery became faint with signs of a rash. She suffered an anaphylactic shock and subsequently died on the 16th January 2014.

1. Action is required to ensure that medication is not administered to a patient to which they are known to have an allergy without advice being sought from a doctor of appropriate designated seniority or experience.

2. Action is required to ensure that consent obtained from a patient as to the administration of medication to which there is a known allergy is informed consent.