Jennifer Tompkins · Prevention of Future Deaths report

On 8 July 2011 I commenced an investigation into the death of Jennifer Tompkins, age 37. The investigation concluded at the end of the inquest on 10 April 2014. The narrative conclusion of the inquest was that Jennifer Tompkins suffered fatal allergic anaphylaxis after receiving an intra venous injection of Tazocin on 6 July 2011 at Kings College Hospital.

Ms Tompkins had focal segmental glomerulosclerosis and was undergoing dialysis while awaiting a kidney transplant. On 6 July 2011 she was admitted to KCH under the care of Dr Kon. A CT scan suggested that Ms Tompkins had an infected pelvic fluid collection for which she was prescribed IV vancomycin and Tazocin, along with cyclizine. These drugs were administered by staff nurse Raul Tindugan. The vancomycin infusion was commenced at 20.07 and the IV cyclizine was given at 20.55 followed by the IV Tazocin. After receiving the Tazocin Ms Tompkins suffered allergic anaphylaxis. The cardiac arrest team were called at 21.00 and arrived at 21.04. Sadly, resuscitation attempts were unsuccessful.

During the inquest I heard from several witnesses including Dr Kon, Mr Tindugen and expert evidence from Dr Peter Jackson, reader in clinical pharmacology at Royal Hallamshire Hospital, Sheffield.

(1) The evidence at the inquest was that IV Tazocin should be given by slow IV injection. Mr Tindugen’s evidence was that he administered this drug over a period of 7 minutes. Even allowing for some uncertainty as to exact timings, the evidence (as set out in the timings given above) suggests that the drug was in fact administered too quickly. I am therefore concerned that there may be training issues relating to the administration of IV medications in this case.

(2) Both Dr Kon and Mr Tindugen gave evidence that the IV vancomycin infusion was stopped early and before it had been fully administered. My concern is that both witnesses said that this fact would not be routinely documented in the drug administration records, and may not be recorded at all. There was no record in this case that the infusion was stopped early.

The evidence at the inquest was that Ms Tompkins’ death was not caused by either of these matters. However, I am concerned that any repetition would cause a risk in other cases.