Marjorie Ellery
PFD Report
All Responded
Ref: 2014-0519
All 1 response received
· Deadline: 21 Jan 2015
Coroner's Concerns (AI summary)
Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.
View full coroner's concerns
During the course of the inquest the evidence revealed a number matters that gave rise to a concern that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken.
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.
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.
Responses
Action Taken
The Trust now requires registrar or higher authorisation and documented discussion with the patient for medication prescriptions when allergies are known. A new policy on allergy management is being developed and training for nursing staff has been reviewed to include the management of allergies. (AI summary)
The Trust now requires registrar or higher authorisation and documented discussion with the patient for medication prescriptions when allergies are known. A new policy on allergy management is being developed and training for nursing staff has been reviewed to include the management of allergies. (AI summary)
View full response
Dear Mr Wickens RE: Mrs Marjorie ELLERY (Deceased) Thank you for your letter dated 27th November 2014 and the attached Regulation 28 Prevention of Future Deaths Report relating to the above named. Thank you for the agreed extension of 2 weeks due to the Christmas and New Year holidays. Regulation 28 highlighted 2 areas of concern: Action is required to ensure that medication is not administered to patient to which are known to have an without advice being sought from a doctor of appropriate designated seniority or experience Action is required to ensure that informed consent obtained from patient as to the administration of medication to which there is a known allergy We have reviewed the concerns raised following the inquest into Mrs Ellerys death and have outlined below the Trust'$ position in relation to the 2 points raised The Trust has made the decision that any patient who requires a medication that they are known to have an allergy to, the decision to give this medication must be authorised by registrar or above and documented in the notes A discussion with the patient must be undertaken by the medical team and consent gained from the patient (if able) or discussed with a relative where applicable and documented in the medical notes and signed by the patient_ patient's red wrist band which denotes an allergy include the name of the and the reaction but no more than 2 drugs recorded on one wrist band_ These significant changes in practice have been presented to, and agreed at, both the Trust Quality Safety Committee and Medication Safety Committee_ The guidance on allergies was included in the Trust's Record Keeping Guideline but as a result of these changes in practice a new policy has been developed on The they allergy drug must The
Commilted xcellence Working Together Facing The Future Frimley Health [ NHS Foundation Trust the Management of Allergies: This is currently out for comment and will be ratified at the Medication Safety Committee on the 18th February 2015. These changes in practice have already been communicated to the medical teams by the Medical Director and the Lead nurses at a variety of Trust Forums and committees The monthly Patient Safety Training for all nursing staff has been reviewed and amended to include training on the management of allergies. In addition, the Trust is in the process of reviewing its current assessment competency for nursing staff to include the changes in practice as part ofthe theory and practical test. The Trust is committed to patient safety and takes cases such as this seriously hope this demonstrated in our response to the concerns you have raised. However, if | can be of any further assistance, please do not hesitate in contacting me
Commilted xcellence Working Together Facing The Future Frimley Health [ NHS Foundation Trust the Management of Allergies: This is currently out for comment and will be ratified at the Medication Safety Committee on the 18th February 2015. These changes in practice have already been communicated to the medical teams by the Medical Director and the Lead nurses at a variety of Trust Forums and committees The monthly Patient Safety Training for all nursing staff has been reviewed and amended to include training on the management of allergies. In addition, the Trust is in the process of reviewing its current assessment competency for nursing staff to include the changes in practice as part ofthe theory and practical test. The Trust is committed to patient safety and takes cases such as this seriously hope this demonstrated in our response to the concerns you have raised. However, if | can be of any further assistance, please do not hesitate in contacting me
Sent To
- Frimley Park Hospital
Response Status
Linked responses
1 of 1
56-Day Deadline
21 Jan 2015
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
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.
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.
Circumstances of the 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 RT4423 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 (Clopigdogrel) 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.
Copies Sent To
Simon Wickens
DATED this 26th day of November 2014
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.