Margaret McNaughton

The Royal Wolverhampton NHS Trust

I am Mrs Joanne Lees Area Coroner for the coroner area of The Black Country.

On 19/12/24 I commenced an investigation into the death of Margaret Ann MCNAUGHTON . The investigation concluded at the end of the inquest on 22/7/25. The medical cause of Mrs McNaughton’s death was found at inquest as; 1a. Respiratory failure due to chronic obstructive pulmonary disease

1. Cardiac Arrest due to Penicillin anaphylaxis

The inquest concluded with a narrative conclusion and an addendum that the death of Mrs McNaughton was contributed to by Neglect.

On 2/12/24 Mrs Margaret MCNAUGHTON was admitted to New Cross Hospital, Wolverhampton with  breathing difficulties and was diagnosed with a respiratory infection. She had a known background of COPD.  Hospital records from her admission recorded that Mrs McNaughton had no known drug allergies (NKDA) but it was unclear where this information had originated from. The EPR showed NKDA and Mrs McNaughton was  reported to have denied any drug allergies when asked by paramedics. It was unclear if the EPR was available in the Emergency Department at the time the records were completed. The triaging Nurse had recorded Mrs McNaughton had NKDA and that Mrs McNaughton denied any drug allergies when asked. Mrs McNaughton did in fact have an allergy to Penicillin. At 2.18 pm on 2/12/24 BEFORE Mrs McNaughton was seen by any clinician she was prescribed I/V co- amoxiclav which is a penicillin based antibiotic. There was no evidence of any allergy checks having been made by the prescribing clinician as to Mrs  McNaughton’s allergy status. The prescribing clinician had not seen or spoken to Mrs McNaughton  themselves. There was no evidence that the prescribing clinician had established the source of entries in the hospital records or accessed the hospital Clinical Web Portal. I found that this was a Gross Failure. The hospital Clinical Web Portal clearly recorded Mrs McNaughton as being allergic to Penicillin with an entry to this effect clearly recorded in May 2023. In addition, by accessing the Clinical Web Portal the GP records for the deceased were also available which if accessed would have shown a recorded allergy to Penicillin in  September 2024. Had the Clinical Web portal been accessed and allergy checks undertaken, then this  information would have been known and McNaughton would not have been prescribed penicillin. Within 25 minutes of the co-amoxiclav being administered intravenously Mrs McNaughton suffered a cardiac  arrest due to penicillin anaphylaxis. She was resuscitated after 4 cycles of CPR and transferred to a ward where she sadly deteriorated with respiratory failure and passed away in hospital on 13/12/24.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

. Allery status checks are both important and essential. At inquest I heard that after the death of Mrs  McNaughton there had been other ‘adverse incidents due to ignoring/not checking allergy status’ . This wording is taken from an email which was disclosed to me by the Hospital Trust as part of their  learning and was sent by the Clinical Director to all clinicians on 13/4/25.  The email goes on to state that no medication will be given without documentation of allergy status by a prescriber and that this must be checked on CWP +/- GP record and corroborated with the patient if they have capacity.

. I was informed that there had been work undertaken at the Trust following an audit in February 2025  which concluded as follows; In conclusion, there continues to be concern with regards to the checking  and confirmation of allergy status and the documentation regarding this. The Directorate feel that  immediate action is required to ensure there is a process in place to reduce the risk of medication  allergy incidents occurring and improve patient safety.

. Although there was no PSIRF investigation carried out after Mrs McNaughton’s death, there was an  internal incident investigation which identified lessons learned as ‘ STATUS MUST BE  CHECKED ON CLINICAL WEB PORTAL AND DOCUMENTED AS SUCH’.

. I am concerned that an email to clinicians and a ‘message of the week’ does not go far enough in terms of the ensuring the Trusts own recognition of ‘lessons learned’ has been embedded across the  Trust and that the requirements to check a patient’s allergy status and record the findings and has not been enshrined in any Trust Policy.

. Given the findings of the Trust from February 2025 and the date of the email sent by the Clinical  Director in April 2025, the inference is that such further incidents have taken place after the death of  Mrs McNaughton and AFTER the message of the week and AFTER the February 2025 audits.  Although  there is evidence that auditing is taking place, given incidents are continuing to occur I am concerned  this presents and continues to present a risk to patient safety at this time.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation/s have the power to take such action.