“Although there were written warnings of Mrs Hammond's allergy on hospital documentation…”

The coroner’s concerns

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— (1) Although there were written warnings of Mrs Hammond's allergy on hospital documentation they appear not to be have been noticed by the nurse who administered augmentin. In an effort to highlight the fact that a patient has an allergy | feel that there needs to be a much clearer indication on the file that the patient has such an allergy. At the inquest, it was suggested that a different coloured file should be used for any patient who has an allergy. Alternatively, a large sticker on the front of the file warning of the allergy would assist. (2) It appears that when Mrs Hammond transferred from the A&E unit to the EAU she was accompanied by a nurse who had little knowledge of Mrs Hammond's condition. As a consequence no discussion took place at the handover regarding the nature of Mrs Hammond's allergy to penicillin. It is felt that if the nurse who had cared for Mrs Hammond in the A&E department had personally accompanied her to the EAU this would have enabled a more productive handover and would have given an opportunity for discussion regarding the allergy. Although | appreciate there may be practical difficulties | would suggest that in future the nurse who has provided care for the patient in A&E should always accompany the patient to the EAU department in order that constructive handover can take place. (3) Your representative at the inquest hearing was not clear as to whether the doctor involved in this case was going to be referred to the General Medical Council and the nurse who administered Augmentin was going to be referred to the Nursing & Midwifery Council it was agreed that he would inform me of this within 14 days of conclusion of the inquest.

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, 2013-0286

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