Peter Rowe
PFD Report
Historic (No Identified Response)
Ref: 2016-0242
Coroner's Concerns (AI summary)
A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy information was accepted uncritically from the patient and an uninformed spouse.
View full coroner's concerns
That despite the GPs referral letter stating an allergy to penicillin, penicillin based prophylactic antibiotic was prescribed and administered. The fact of the GPs referral letter stating an allergy to both penicillin and aspirin appears to have been transferred on to the Adult Inpatient Prescription and Administration record and then deleted, albeit it is not clear by whom and when: On the evidence heard at the Inquest Mr Rowe suffered from very poor memory following his stroke in 1993. In the premises am concerned that negative answers to questions regarding any allergies stated to have been put to both Mr Rowe and were accepted at face value when, a) Mr Rowe suffered from significant memory loss and decreased cognitive function, and b) Whent would not necessarily have known of her husband's allergy (and indeed did not) MATTER OF CONCERN is as follows; In my opinion there is a risk that a similar situation may arise in the future and as such there is a risk that future deaths will occur unless action is taken, my concerns
Sent To
- Central Manchester University Hospitals NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
24 Aug 2016
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 11th February 2016 an investigation was commenced into the death of Peter Arthur Rowe who died while an in-patient at Stepping Hill Hospital, Stockport on 8" February 2016, having been admitted on 1s February 2016_ The investigation concluded with an Inquest held on 8ih June 2016. Medical cause of death Ia) Multi-organ failure Ib) Sepsis Ic) Toxic epidermal necrolysis Psoriasis Cerebrovascular accident In answer to the questions 'how; when and where' the findings were as follows, On the 26" January 2016 Peter Arthur Rowe was admitted to Manchester Royal Infirmary for case general anaesthesia for removal of a lipoma his back Co-amoxiclav was administered as a prophylactic antibiotic, notwithstanding the GP referral letter stated a penicillin allergy as of 2004. Mr and stated that they were unaware of any allergies upon being asked that specific question in the pre-operative consultations and assessments. The Adult Inpatient Prescription and Administration record; dated 26" January 2016, notes in the section Allergies/Intolerances a penicillin and aspirin allergy which is then crossed out and the signed as no known allergies Following discharge Peter Arthur Rowe developed a red scaly rash which worsened and on the February 2016 he was admitted to Stepping Hill Hospital with an initial diagnosis of an infected (pustulated) psoriasis, which was changed the following to Toxic Epidermal Necrolysis, the pathogenesis of which was the administration of prophylactic co-amoxiclav on the likely Dathogen2oi. Peter Arthur Rowe continued to deteriorate and died on the &h February 2016. CONCLUSION: Misadventure
Circumstances of the Death
circumstances are as described above day from box 7st day The
Action Should Be Taken
In my opinion action should be taken to develop a system; and to ensure its operation, such that in circumstances where a patient is stated to have an allergy by referring doctor or other healthcare provider the fact of that statement should not be ignored unless the patient him/herself is of full capacity and full cognitive function and is able to deny any allergy so stated or the referring doctor is contacted for confirmation or further information.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.