Margaret McNaughton

1 Aug 2025 · Coroner Joanne Lees · The Black Country

The coroner's concerns

1. medication allergy incidents
“Allery status checks are both important and essential.”
2. lack of documented allergy status checks
“STATUS MUST BE CHECKED ON CLINICAL WEB PORTAL AND DOCUMENTED AS SUCH”
3. unverified allergy status documentation
“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”
4. unclear allergy status verification process
“it remains unclear as to how such checks should be carried out (e.g use of CWP; two sources, timing of the recording of information etc..) and where information about such checks should be recorded”
5. missing prescriber verification of allergy source
“there is no apparent requirement for a prescriber to record that they have either checked the patient's allergy status themselves before prescribing OR checked the source of the information contained within the hospital records”