Vital information on patient not available to Telford hospital doctor, inquest told
The one vital piece of information that could have prevented a pensioner being given a drug to which she had an allergy was not available to the Telford hospital doctor treating her, Shropshire's coroner has said.
Mr John Ellery said he would now be writing to the Shrewsbury and Telford Hospitals Trust and the Care Co-ordination Centre (CCC) to make sure lessons were learned from the death Mrs Iris Dorothy Richardson from Bridgnorth.
Mrs Richardson died in the Princess Royal Hospital on April 3 this year from heart failure after suffering an anaphylactic shock caused by an allergy to the antibiotic flucloxacillin, prescribed to treat cellulitis in her legs.
Mr Ellery recorded a verdict that Mrs Richardson died as a result of system failure after it emerged a letter from her GP, which highlighted the allergy, was not available to the hospital doctor who prescribed the drug.
When a patient is referred to the hospital by their GP, a letter giving the patient's background is supposed to be faxed to the hospital by the CCC, the organisation which liaises between doctors and hospitals to find hospital beds.
He said: "It seems to me that within the system no one individual could be said to have caused it. It was a system failure."
He added: "I am going to write to the hospital and the CCC so that they address this. It is a matter of concern that anecdotally this is not an isolated situation. What's the point of sending in a GP referral if those making decisions don't know why there has been a referral?
"I am satisfied that those matters in the hospital are being addressed so that once they have the information they can deal with it, but if they don't get past first base the system remains flawed. "
Dr Edwin Borman, medical director of SaTH, said that as a result of the inquiry following Mrs Richardson's death, the hospital's internal computer systems were being changed to make sure known allergies were prominently visible on patient records.
The inquest heard that Dr Beata Kodz-Gibb , who prescribed the antibiotic, did not have the GP referral letter or Mrs Richardson's full notes when making her decision. She had access to a computer programme called escript but did not know that asterisks in one of the fields meant that there was extra information.
The hidden information suggested Mrs Richardson had a sensitivity to flucloxacillin, rather than the true allergy which caused her death, but Dr Kodz-Gibb said it would have been enough to prevent her prescribing the drug.
Dr Borman said escript was a programme intended for use by pharmacists rather than doctors and Dr Kodz-Gibb had only looked at it because she was 'more diligent' than she needed to be.
