“(brief summary of matters of concern) The deceased's medical notes contained at least…”
Dated 5 Apr 2022, from the coroner for Hampshire, Portsmouth and Southampton. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 31 May 2022.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated5 Apr 2022
- Deadline31 May 2022
- Published on judiciary.uk26 Apr 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Portsmouth Hospitals University NHS TrustNamed in the report as “Portsmouth Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in April 2022. |
The coroner’s concerns
(brief summary of matters of concern) The deceased's medical notes contained at least seven entries indicating the deceased had a sensitivity to chloramphenicol, the first such entry being recorded in 1997. Those medical notes included notes made by the Queen Alexandra Hospital, Portsmouth in which the deceased's recorded allergies included chloramphenicol. Evidence was adduced that had the clinicians involved in the care and treatment of the deceased in September 2020 had knowledge of those notes and/or the deceased's sensitivity to chloramphenicol had been flagged in the medical records during the deceased's September 2020 admission chloramphenicol would not have been prescribed to the deceased. My concern is that relevant, critical information relating to the care and treatment of the deceased was in existence but was not accessible nor flagged up to those involved in the Regulation 28 – After Inquest Document Template Updated 30/07/2021 care and treatment of the deceased. In the absence of a process where relevant, critical information is not accessible nor flagged up to clinicians there continues to be a future risk to life.
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, 2022-0099
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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