“Allery status checks are both important and essential”

The coroner’s concerns

– 1. Allery status checks are both important and essential. At inquest I heard that after the death of Mrs McNaughton there had been other ‘adverse incidents due to ignoring/not checking allergy status’. This wording is taken from an email which was disclosed to me by the Hospital Trust as part of their learning and was sent by the Clinical Director to all clinicians on 13/4/25. The email goes on to state that no medication will be given without documentation of allergy status by a prescriber and that this must be checked on CWP +/- GP record and corroborated with the patient if they have capacity. 2. I was also informed at inquest that this email had been preceded by a ‘message of the week’ which required a number of actions (albeit it was unspecific as to whom should be carrying out these actions i.e. medical or clinical staff). This message required two sources to confirm the allergy status and for the source to be documented. 3. I was informed that there had been work undertaken at the Trust following an audit in February 2025 which concluded as follows; In conclusion, there continues to be concern with regards to the checking and confirmation of allergy status and the documentation regarding this. The Directorate feel that immediate action is required to ensure there is a process in place to reduce the risk of medication allergy incidents occurring and improve patient safety. 4. Although there was no PSIRF investigation carried out after Mrs McNaughton’s death, there was an internal incident investigation which identified lessons learned as ‘STATUS MUST BE CHECKED ON CLINICAL WEB PORTAL AND DOCUMENTED AS SUCH’. 5. I am concerned that an email to clinicians and a ‘message of the week’ does not go far enough in terms of the ensuring the Trusts own recognition of ‘lessons learned’ has been embedded across the Trust and that the requirements to check a patient’s allergy status and record the findings and has not been enshrined in any Trust Policy. 6. Given the findings of the Trust from February 2025 and the date of the email sent by the Clinical Director in April 2025, the inference is that such further incidents have taken place after the death of Mrs McNaughton and AFTER the message of the week and AFTER the February 2025 audits. Although there is evidence that auditing is taking place, given incidents are continuing to occur I am concerned this presents and continues to present a risk to patient safety at this time. 7. The Trusts Policy on Prescribing, storage and administration of drugs states; ‘it is the responsibility of a registered medical or dental officer to prescribe for a patient It is the responsibility of the prescriber to take a medication history and complete the drug allergy box’. Again, whilst accepting this I cannot see anything in this policy that addresses my concern as to HOW this is carried out. 8. The Trusts Policy on Electronic Prescribing and Medicines Administration (ePMA) Policy outlines how the ePMA system must be used within the Trust. It provides an electronic system for prescribing, clinical checking, supplying, and administering medication. The Policy states that the system must enable the Trust to reduce the risk of medication errors and that the ePMA system also provides a Decision Support System (DSS) to aid safer prescribing and administration. The Policy states ‘Prescribers are responsible for entering allergy details into the patient’s medical record within ePMA as part of their clerking, and thereafter regularly reviewing the allergy details. Again, whilst accepting this I cannot see in this policy anything specific about HOW such checks should be carried out and 2 when. 9. The Trusts Management of Medication Errors Policy states; it is the responsibility of a registered medical [or dental officer] to prescribe for a patient. It is the responsibility of the prescriber to take a medication history and complete the drug allergy box’ again accepting this, the policy otherwise deals with how errors are reported and dealt with, and does not appear to cover my concerns outlined above. 10. I cannot see any Trust Policy that provides guidance on HOW a patients allergy status should be checked or recorded and by whom and where - over and above a prescribers professional responsibility and accountability. 11. I am concerned that it remains unclear as to how such checks should be carried out (e.g use of CWP; two sources, timing of the recording of information etc..) and where information about such checks should be recorded. I am concerned this presents a risk to patient safety at this time. 12. I am also concerned that there is no apparent requirement for a prescriber to record that they have either checked the patient’s allergy status themselves before prescribing OR checked the source of the information contained within the hospital records. I am concerned this presents a risk to patient safety at this time. 13. After reviewing the Policies provided to me, I also noted in The Trusts Management of Medication Errors Policy it defines level 1 and level 2 errors. I do not know what Level the incident concerning Mrs McNaughton was graded as but a level 2 error includes ‘Errors resulting in actual patient harm i.e. any physical effect to a patient that is directly a result of a medication error’. The incident report that I have been provided with only refers to an ‘amber’ incident. I understand the prescriber concerned in this case was a locum doctor and the policy states; In the event of a locum doctor making an error the WMI will forward the report to both HR and the clinical lead for the doctor’s specialty’. The Policy also states ‘The doctor will be counselled by their educational supervisor or clinical lead at the time of the incident who will require them to reflect on their practice. Suspension of a doctor from prescribing or administration of medicines will only occur if the doctor, their educational supervisor or clinical lead asses

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0397

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0