Oriel Vasey
PFD Report
All Responded
Ref: 2026-0124
All 1 response received
· Deadline: 1 May 2026
Coroner's Concerns (AI summary)
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient care, with a risk of recurrence as the process remains unaddressed.
View full coroner's concerns
as follows: –
1. This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.
2. If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies. That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record.
1. This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.
2. If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies. That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record.
Responses
Action Taken
• The standard ICB Nursing Needs Assessment form has been re-issued to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW). • The ICB has requested that CNTW remove the allergy section from their version of the form. • The ICB will work with CNTW to ensure that staff are aware of the correct form to use and the importance of accurate record keeping. (AI summary)
• The standard ICB Nursing Needs Assessment form has been re-issued to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW). • The ICB has requested that CNTW remove the allergy section from their version of the form. • The ICB will work with CNTW to ensure that staff are aware of the correct form to use and the importance of accurate record keeping. (AI summary)
View full response
Dear Mrs Combes,
Re Regulation 28 Report to Prevent Future Deaths - Oriel Vasey
Thank you for your Report to Prevent Future Deaths dated 4th March 2026 concerning the death of Mrs Oriel Vasey on 5th March 2025. In advance of responding to the actions raised in your report, I would like to express my deep condolences to Mrs Vasey's family.
The response from the North East and North Cumbria Integrated Care Board (NENC ICB) to your concerns is as follows:
Concerns: This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.
If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies. That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record.
Following an internal investigation, I can confirm that the form in question is an 'assessment of nursing needs' proforma, designed by the ICB. The purpose of the form is to bring together the information from a patient's assessment of needs and in order to make recommendations regarding eligibility for NHS All Age Continuing Healthcare (AACC) funding. The version of the form held by the ICB does not request any allergy information and there is no section to record allergies.
The form used by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) appears to have been adapted to include a section on allergies.
2
This adapted form was completed by a member of staff at CNTW who used a form already completed for another patient and overwrote that patient's details with those of Mrs Vasey's, mistakenly leaving the information to the previous patient's allergy history in situ.
To future safeguard against this reoccurring the ICB have implemented several actions as follows:
• The standard ICB Nursing Needs Assessment form has been amended to make it clear the form is the property of the ICB and should not be modified.
• The new form has been circulated to all All Age Continuing Care teams across the ICB's geographical footprint including version control.
• The updated form has been circulated to NENC NHS Trusts and will be available on the ICBs website.
• We have spoken with CNTW, and they have assured us that the adapted form has been taken out of circulation.
• The ICB will check the use of the correct form in all our panels to ensure no other adaptions have been made by partner agencies and will continue to do so periodically.
In summary, to address the concerns raised, the only form available from the ICB does not contain allergy information, and it explicitly states the form must not be modified.
Thank you for bringing this important patient safety concern to my attention and please do not hesitate to contact me should you require any further information.
Re Regulation 28 Report to Prevent Future Deaths - Oriel Vasey
Thank you for your Report to Prevent Future Deaths dated 4th March 2026 concerning the death of Mrs Oriel Vasey on 5th March 2025. In advance of responding to the actions raised in your report, I would like to express my deep condolences to Mrs Vasey's family.
The response from the North East and North Cumbria Integrated Care Board (NENC ICB) to your concerns is as follows:
Concerns: This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.
If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies. That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record.
Following an internal investigation, I can confirm that the form in question is an 'assessment of nursing needs' proforma, designed by the ICB. The purpose of the form is to bring together the information from a patient's assessment of needs and in order to make recommendations regarding eligibility for NHS All Age Continuing Healthcare (AACC) funding. The version of the form held by the ICB does not request any allergy information and there is no section to record allergies.
The form used by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) appears to have been adapted to include a section on allergies.
2
This adapted form was completed by a member of staff at CNTW who used a form already completed for another patient and overwrote that patient's details with those of Mrs Vasey's, mistakenly leaving the information to the previous patient's allergy history in situ.
To future safeguard against this reoccurring the ICB have implemented several actions as follows:
• The standard ICB Nursing Needs Assessment form has been amended to make it clear the form is the property of the ICB and should not be modified.
• The new form has been circulated to all All Age Continuing Care teams across the ICB's geographical footprint including version control.
• The updated form has been circulated to NENC NHS Trusts and will be available on the ICBs website.
• We have spoken with CNTW, and they have assured us that the adapted form has been taken out of circulation.
• The ICB will check the use of the correct form in all our panels to ensure no other adaptions have been made by partner agencies and will continue to do so periodically.
In summary, to address the concerns raised, the only form available from the ICB does not contain allergy information, and it explicitly states the form must not be modified.
Thank you for bringing this important patient safety concern to my attention and please do not hesitate to contact me should you require any further information.
Sent To
- NHS North East and North Cumbria Integrated Care Board
Response Status
Linked responses
1 of 1
56-Day Deadline
1 May 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 13th August 2025 I commenced an Investigation into the death of Mrs Oriel Vasey, who died in Sunderland on 5th March 2025 aged 88 years. The Investigation concluded at the end of the Inquest on 16th December 2025.
I gave the following narrative conclusion: -
Oriel Vasey died on 5 March 2025 at Sunderland Royal Hospital. She had developed a pressure area on her sacrum which deteriorated and resulted in the development of sepsis. This sepsis was treated at hospital but unfortunately caused Oriel's death.
The medical cause of death was confirmed as: - Ia. Infected pressure sore Ib. frailty of old age II. Alzheimer's dementia
I gave the following narrative conclusion: -
Oriel Vasey died on 5 March 2025 at Sunderland Royal Hospital. She had developed a pressure area on her sacrum which deteriorated and resulted in the development of sepsis. This sepsis was treated at hospital but unfortunately caused Oriel's death.
The medical cause of death was confirmed as: - Ia. Infected pressure sore Ib. frailty of old age II. Alzheimer's dementia
Circumstances of the Death
Oriel Vasey was admitted to Regents View Care Home having been detained under s3 of the Mental Health Act and spent a period of time under the care of the Mental Health Trust.
As is routine, at the point a person is eligible for discharge from the Mental Health Act, the relevant Integrated Care Board and the Local Authority, are asked to consider the funding and placement arrangements for that person who is eligible for support under s117 of the Mental Health Act 1983. As part of this process a form is completed by the mental health team which identifies what needs that person has.
Page 2 of 3
In Oriel's case this form had been completed by a nurse, and during the Inquest it became clear that a previous service user’s form had been used as the starting point, and unfortunately erroneous information had been left on the form in respect of allergies. The form in Oriel's case therefore retained a reference to a penicillin allergy which was not the case for Oriel.
During the Inquest, evidence confirmed that this form was intended purely for the allocation of funding and was not intended to form part of the patient’s clinical record. However also in evidence was that in Oriel's case the erroneous information from this form had been added into her clinical record and as a result, when infection was identified, penicillin as the first line antibiotic, was ruled out by doctors treating her. This happened on a number of occasions although in Oriel's case I could find no evidence that this would have changed the outcome for her.
Family raised concerns with clinicians that she had previously had penicillin to good effect but the GP was unable to amend the record because this had come from an official source and therefore the risk of amending allergy information on the basis of information from family members was greater than the risk of working on the basis of the allergy information being correct.
As is routine, at the point a person is eligible for discharge from the Mental Health Act, the relevant Integrated Care Board and the Local Authority, are asked to consider the funding and placement arrangements for that person who is eligible for support under s117 of the Mental Health Act 1983. As part of this process a form is completed by the mental health team which identifies what needs that person has.
Page 2 of 3
In Oriel's case this form had been completed by a nurse, and during the Inquest it became clear that a previous service user’s form had been used as the starting point, and unfortunately erroneous information had been left on the form in respect of allergies. The form in Oriel's case therefore retained a reference to a penicillin allergy which was not the case for Oriel.
During the Inquest, evidence confirmed that this form was intended purely for the allocation of funding and was not intended to form part of the patient’s clinical record. However also in evidence was that in Oriel's case the erroneous information from this form had been added into her clinical record and as a result, when infection was identified, penicillin as the first line antibiotic, was ruled out by doctors treating her. This happened on a number of occasions although in Oriel's case I could find no evidence that this would have changed the outcome for her.
Family raised concerns with clinicians that she had previously had penicillin to good effect but the GP was unable to amend the record because this had come from an official source and therefore the risk of amending allergy information on the basis of information from family members was greater than the risk of working on the basis of the allergy information being correct.
Copies Sent To
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and their Solicitors
South Tyne and Sunderland NHS Foundation Trust
Regents View Care Home and their Solicitors
Hetton Medical Centre and their Solicitors
Care Quality Commission
Page 3 of 3
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.