Allergy form mistake led to worse care - coroner
STSFTA mistake on a medical form led to the "sub-optimal care" of an 88-year-old sepsis patient, a coroner has said.
Abigail Combes, assistant coroner for Sunderland, wrote to the North East and North Cumbria Integrated Care Board (ICB) about the handling of a form which mistakenly noted that Oriel Vasey had a penicillin allergy.
The coroner said she could find "no evidence" this mistake had caused Vasey's death but it had led to her receiving worse care.
The ICB said it was saddened by Vasey's death. "We take all concerns very seriously and we are working with our NHS partners to carefully review the coroner's findings," it said.
Vasey died at Sunderland Royal Hospital on 5 March 2025 after she developed sepsis, according to the coroner's report.
It said she had previously had a form, which is the responsibility of the ICB, filled out by her mental health team which detailed her particular needs for funding purposes.
However, it had been filled out mistakenly to say that Vasey had a penicillin allergy.
Though the form was only for funding purposes, the coroner said, the error was added to Vasey's clinical record and meant she was not given the antibiotic as a first-line treatment in hospital.
'No role in death'
Combes said Vasey's family had told clinicians the 88-year-old had faced no adverse effects from the antibiotic in the past, but overturning Vasey's clinical record based on the recollections of her family would have been too great a risk.
The coroner said she had found no evidence the allergy mistake had played a role in Vasey's death but nevertheless questioned how a form used for funding purposes could have affected a patient's clinical record.
She also questioned why the form had asked about the patient's allergies in the first place, if it was only for financial decision making.
Combes said there was a risk of future deaths, unless action was taken regarding the process of handling the forms, which remains unchanged.
The ICB has until 1 May to respond to the concerns raised by the coroner.
