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recurance

Nicos Michael

14 Apr 2014 · Coroner Rebecca Cobb · Kent (North-East)

The coroner's concerns

  1. 1. conflicting allergy documentation

    “There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen).”
  2. 2. allergy information not transferred between records

    “The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP.”
  3. 3. inadequate allergy data availability

    “The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital's staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence”

Responses

2014-0168-Response-by-East-Kent-Hospitals-University.pdf ↗· East Kent Hospitals University NHS Foundation Trust

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Nicos Michael · Recurance