19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that the Practice was wrong by prescribing Mr P with amoxycillin. This does not detract from the upset that this caused.
20. Mrs P has told us that Mr P was allergic to penicillin, and that this was noted within his medical files. Despite this, the Practice prescribed Mr P amoxicillin on 6 September 2023.
21. Mr P had been prescribed doxycycline the day before by the hospital, however, this caused a rash which was thought to be caused by the medication.
22. Mrs P complains that the practice then decided to prescribe Mr P amoxicillin instead of him continuing the doxycycline, despite him being allergic.
23. Mr P was then admitted to hospital on 9 September 2023, and whilst he was there, he was diagnosed as having as having a penicillin rash which was bright red and flaking off. Mrs P says her husband endured six weeks of pain and discomfort from the reaction, and his skin remained sensitive for a further five months.
24. Mrs P says Mr P was already very unwell, and that the rash only added to this. She was also his main carer, and it was distressing for her to see the extent of the rash and how it impacted him.
25. Within its complaint response letter dated 29 October 2023, the GP practice acknowledged that a conversation took place between a paramedic and the Practice on 6 September 2023. It was informed Mr P had taken one dose of doxycycline, and a description of the rash was given.
26. The Practice recalled the consultation from 6 September 2023. It acknowledged penicillin had previously caused Mr P to develop a rash. The Practice considered the rash to be an intolerance to penicillin, rather than a reaction as there had never previously been any anaphylaxis allergic reaction. A risk assessment was made, and it was decided to trial Mr P on amoxicillin.
27. Anaphylaxis is a severe, life-threatening allergic reaction. It can occur seconds or minutes after exposure to an allergen, such as peanuts or bee stings. Symptoms include difficulty breathing, swelling, hives, and shock. Anaphylaxis can be fatal and requires immediate treatment, such as using an epinephrine injector.
28. The Practice explained Mr P was known to have an intolerance to several antibiotics. It said that, as per the local guidance of Northwest London, the choice of suitable medication can be limited for Mr P. It said antibiotics were important to prevent the exasperation of Mr P’s chest infection. It therefore decided to trial a prescription of amoxicillin to treat Mr P’s chest infection, given his chest infection was more harmful to Mr P’s health than an intolerance rash.
29. From viewing Mr Ps medical records, it states that Mr P had a sensitivity to penicillin and that this caused a rash, rather than an allergy that causes anaphylaxis. Throughout his medical records, he was prescribed numerous alternatives to penicillin such as clarithromycin, erythromycin and doxycycline.
30. We refer to the NHS Northwest London Integrated Care Board’s guidance on Antimicrobial Prescribing Guidelines for Primary Care, which the Practice has also referred to within its complaint response. The guidance says that amoxicillin would be the first choice for upper respiratory infections (chest infections), and then then either clarithromycin or erythromycin should be prescribed if amoxicillin does not work.
31. The Practice acknowledged Mr P had an intolerance to penicillin/amoxicillin. Mr P had to stop the doxycycline which was also causing him to develop a rash.
32. To help us understand the difficulties in prescribing antibiotics, we sort advice from our adviser. As reflected in the above guidelines, our clinical adviser has said that erythromycin or clarithromycin would have been alternatives to amoxicillin.
33. Our adviser noted Mr P was also being prescribed cabergoline to treat high levels of prolactin in his blood. Our adviser stated erythromycin or clarithromycin would have interacted with cabergoline and so there was a limited choice of antibiotics that could be used to treat his chest infection.
34. We also refer to NHS guidelines, ‘Do I have a penicillin allergy?’, which says that:
‘Side effects are different to allergic reactions. Having a side effect to penicillin, while unpleasant, does not mean you need to completely avoid penicillin antibiotics. This is particularly true in severe infections where penicillin may be the best treatment.
Around 1 out of every 10 people report having an allergy to penicillin. However, evidence suggests that more than 9 out of 10 people who report an allergy to penicillin might not be allergic to the medication. They may have had side effects from taking penicillin.
About 1 in every 100 people have a genuine penicillin allergy. The most severe allergy, anaphylaxis, happens in about 1 in every 10,000 people taking penicillin. This means that a severe allergy is rare.’
35. Our adviser said it was not unreasonable to try amoxicillin to treat Mr P’s chest infection, as there was a good possibility Mr P’s sensitivity to penicillin may not have been as severe when he was prescribed amoxicillin due to it not being as potent as pure penicillin.
36. Lastly, it important to note that as Mr P already had a rash from the doxycycline, and this may have exacerbated any rash caused by the amoxicillin.
37. It is understandable Mr and Mrs Ps may have been worried, and we understand the concerns she has raised surrounding the incident. We do understand how upsetting this has been.
38. We have not seen any indication of failings in the Practice’s actions of trialling amoxycillin. We feel the Practice had a limited choice of antibiotics to trial and it was necessary to treat Mr P’s chest infection.
39. This does not detract from the distress caused, and we are grateful for Mrs P for bringing this case to our attention.