“are as f ollows:Prescribing and dispensing errors 1”

The coroner’s concerns

are as f ollows:Prescribing and dispensing errors 1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies; 2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim. 3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient saf ety is maximised. 4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs. 5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. Pharmaceutical product allergies to be noted on patient records not only by the constituent drug name but also the name of the drug being prescribed in this cas e, t he antibiotic Co-trimoxazole. Prescriptions to be noted on medical records/patient notes and discharge let t ers by both their brand names and generic pharmaceutical names. Prescriptions to be noted on medical records/patient notes and discharge let t ers by brand/generic name as well as constituent components e.g. Co-trimoxazole comprises trimethoprim and sulfamethoxazole. Mr. Compton’s discharge letter states his allergy was to trimethoprim. An inability to circumnavigate known allergy information b y Us ers of t he elect ronic prescribing tool (eDAL) 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 May 2022, allowing for statutory holidays. I may extend this period upon request.

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, 2022-0090

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