Have a read of the Case Study below where a tragic mistake resulted in a pencillin-based antibiotic (Magnapen® = co-fluampicil) being prescribed and administered to a penicillin allergic patient.

Case Study
Article on death of Teresa Innes

Teresa died 'after series of blunders'

A "catalogue of mistakes" led to the tragic death of Bradford mum Teresa Innes, an inquest ruled today.
Bradford Coroner Roger Whittaker said that he would be writing to the Royal College of Surgeons expressing his concern that surgeons do not routinely check patients' allergy statuses after hearing how JG recommended a penicillin-based drug without checking Miss Innes's notes first.
Expert witness Robin Ferner had told Mr Whittaker that the failure to make the proper checks had been like "the responsibility of a captain of a cross-channel ferry leaving port with its bow doors open". Mr JG had claimed that he had not actually prescribed the penicillin-based drug but merely recommended that it be prescribed but, strongly criticising the consultant, Mr Whittaker said Mr JG had "done himself little credit by that attempt to avoid responsibility".
He added: "At whatever level or discipline, surgeon or nurse, they are all involved and they all have a responsibility, but in my view it starts at the top."
The coroner also called for better labelling of medication and said that he would be writing to those who train doctors recommending that they all should be better taught in the safe prescribing of medication. Recording his narrative finding, Mr Whittaker also called for better continuity of care after hearing how Miss Innes's notes had got lost. "Staff with care for any patient should keep themselves up to date and ascertain why patients are there immediately after coming on duty."
The week-long inquest had been told that Miss Innes had been given a bright red allergy wrist band to wear but it was not seen by Mr JG or Dr JS who was told to write the prescription for magnapen. Nurse BC who made up the prescription did know of her severe allergy but did not know that magnapen contained penicillin. "If each of these three had checked as they should, if the band had been noticed, we would not be here today."
Mr Whittaker recorded a narrative verdict which said that Miss Innes had told staff about her allergy and had even asked one nurse to write it in capital letters and underline it on her notes.
Mr Whittaker added: "During the ward round the surgeon recommended that she be prescribed magnapen. At the time he was not aware of her allergy or previous reaction. A junior doctor, eight weeks post qualification who had not been present when Teresa was examined and was also unaware of her allergy, was then instructed by the surgeon to write out a prescription for the drug."
Miss Innes, was 38 when the High Court ruled that life supporting treatment could be withdrawn, suffered an anaphylactic reaction immediately after she was given the drug and was left in a coma for two years.
A spokesman for Bradford Teaching Hospitals NHS Foundation Trust said after wards: "We very much regret what happened in September 2001 and would like to take this opportunity of expressing once again our sympathies to Teresa's family and friends.
"We welcome the coroner's comments that our systems were not responsible for the tragedy."

Copyright eBook 2019, University of Leeds, Leeds Institute of Medical Education.