Tripta Rani Kumar
PFD Report
Historic (No Identified Response)
Ref: 2013-0235
Coroner's Concerns (AI summary)
A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk of anaphylaxis.
View full coroner's concerns
In the emergency department, during the course of treatment given on the 24th August 2012, the deceased was attended to by an ST4, doctor in Obstetrics and Gynaecology. The doctor documented the likely diagnosis, requested an urgent CT scan and prescribed intravenous antibiotics in the form of Tazocin. Tazocin contains two active ingredients, Piperacillin, which is a penicillin type antibiotic and Tazobactum which is a medicine that prevents bacteria from inactivating Piperacillin. Evidence from the family of the deceased, confirmed by
(Consultant in Accident and Emergency), revealed that the notes clearly showed that the patient had a penicillin allergy. The family of the deceased also confirmed in court that their mother was wearing a band on her wrist which confirmed the penicillin allergy. further confirmed that the entry in the notes that said ‘penicillin allergy’ had been crossed out and the note ‘nil allergies’ had been entered instead. This was in handwriting but with no signature to confirm who had written the note. The grave danger is that, although not relevant in this particular case, giving someone penicillin who was allergic to that penicillin could easily have resulted in anaphylactic shock which, in turn, could have resulted in death.
(Consultant in Accident and Emergency), revealed that the notes clearly showed that the patient had a penicillin allergy. The family of the deceased also confirmed in court that their mother was wearing a band on her wrist which confirmed the penicillin allergy. further confirmed that the entry in the notes that said ‘penicillin allergy’ had been crossed out and the note ‘nil allergies’ had been entered instead. This was in handwriting but with no signature to confirm who had written the note. The grave danger is that, although not relevant in this particular case, giving someone penicillin who was allergic to that penicillin could easily have resulted in anaphylactic shock which, in turn, could have resulted in death.
Sent To
- Queen’s Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
23 Mar 2014
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 30th August 2012 I commenced an investigation into the death of Tripta Rani KUMAR,69 years. The investigation concluded at the end of the inquest on 4th September 2013. I concluded with the narrative “The deceased undertook routine, planned vaginal hysterectomy and anterior repair on 21st August 2012 before being discharged on 23rd August. She was readmitted on the 24th August 2012 with overwhelming sepsis as a result of bowel perforation likely incurred during the procedures carried out on 21st August. She died as a result.” The medical cause of death was 1a. Multiple Organ Failure, 1b. Organising Peritonitis, 1c. Perforation of Large Bowel (repaired), II. Old Empyema of chest
Circumstances of the Death
1. The deceased had a planned hysterectomy for a prolapse on Tuesday 21st August and was discharged on 23rd August 2012.
2. She was readmitted on the 24th August 2012 complaining of abdominal pain and found to have a perforated bowel.
3. Hartmans procedure completed but she was septic by this stage. Maximum treatment continued post operatively in ITU but she suffered a cardiac arrest on the 25th August 2012.
4. CPR was given but she died despite efforts made.
2. She was readmitted on the 24th August 2012 complaining of abdominal pain and found to have a perforated bowel.
3. Hartmans procedure completed but she was septic by this stage. Maximum treatment continued post operatively in ITU but she suffered a cardiac arrest on the 25th August 2012.
4. CPR was given but she died despite efforts made.
Action Should Be Taken
It is clear there should be a review of the systems in place that are meant to ensure there is no risk of anaphylactic shock in such cases. In addition, the operation of the system should be audited on a regular basis since potential consequences of absence of or poor operation of such systems are potentially so serious.
7. You are under a duty to respond to this report within 56 days of the date of this report namely by 15th November 2013. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
7. You are under a duty to respond to this report within 56 days of the date of this report namely by 15th November 2013. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.