A coroner has asked a hospital trust to explain its policy on patients’ allergy status following the death of a patient who was given a penicillin-based antibiotic, despite her GP record showing a known allergy to the drug.
Joanne Lees, an area coroner for the Black Country, issued a Prevention of Future Deaths report on 4 August 2025, following the death of Margaret McNaughton, who died at New Cross Hospital, Wolverhampton, on 13 December 2024.
The report stated that McNaughton’s GP records and the hospital Clinical Web Portal noted a previous allergic reaction to penicillin, but it said that hospital records from her admission recorded that she had no known drug allergies (NKDA).
“It was unclear where this information had originated from,” the report said.
“The EPR [electronic patient record] 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.”
The inquest recorded two causes for McNaughton’s death: respiratory failure owing to chronic obstructive pulmonary disease; and cardiac arrest resulting from penicillin anaphylaxis.
The coroner stated that her death was also “contributed to by neglect”.
The report said there was “no evidence” that the prescribing clinician had made any allergy checks, including checking the hospital Clinical Web Portal, and “had not seen or spoken to Mrs McNaughton themselves,” concluding this as a “gross failure”.
The report also raised concerns about the Royal Wolverhampton NHS Trust’s reliance on clinician responsibility rather than “embedded” policy requirements for allergy checks.
The inquest heard that previous adverse incidents had taken place before this incident “due to ignoring/not checking allergy status,” as worded in an email from the trust to all clinicians on 13 April 2025 and disclosed to the coroner.
The coroner has asked the trust to outline actions taken or proposed to prevent future deaths.
When asked for a response to the report and how the trust manages allergy checks in prescribing, Joe Chadwick-Bell, group chief executive of the Royal Wolverhampton NHS Trust, told The Pharmaceutical Journal: “We would like to offer our sincere condolences to Mrs McNaughton’s family.
“The trust takes patient safety extremely seriously and a number of additional improvements have been put into place following Mrs McNaughton’s death, which address the concerns highlighted within the coroner’s report.
“We will respond fully to the coroner’s report within the 56 days required, outlining all measures taken to improve medicine safety.”
Commenting on the coroner’s report, Neil Powell, consultant antibiotic pharmacist at the Royal Cornwall Hospital, stressed that the findings should not deter efforts to de-label patients wrongly identified as having a penicillin allergy.
“Anaphylaxis to penicillin is rare, but it’s serious, and we need to try and identify patients who are at risk of anaphylaxis and make sure we don’t expose them to penicillin,” he said.
For pharmacists involved in allergy testing for penicillin, Powell stressed the importance of taking “a structured penicillin allergy history from patients, and risk assessing them before we challenge-test them to prevent reactions like this from happening”.
He added that more detailed recording of allergic reactions in GP records would help clinicians make informed decisions about whether to supply penicillin in an emergency situation.
For instance, Powell suggested that a patient who had previously experienced a mild gastrointestinal side effect or mild rash could still be given penicillin in an emergency situation, if the clinician had determined the risk to be worth the benefit.
However, he added that the systems currently in use by GPs and hospitals to record allergy information “do not lend themselves to writing any details about what happened”.
Amena Warner, head of clinical services at Allergy UK, said: “Allergy to medicines is one of the biggest causes of anaphylaxis in adults. A big part of healthcare is medication prescribing and administration, especially in hospitals, so robust policies and procedures should be in place to protect the sick and vulnerable people in their care, taking into account any past adverse reactions or allergies to medication, so these medicines are not given to people inadvertently.
“Penicillin is widely used and to those that have an allergy to it, avoidance is the key management strategy.
“There is a national drive to de-label those with an incorrect penicillin label, but this needs assessment and should not stop the avoidance of penicillin in those that are truly allergic to penicillin.”
In July 2025, study results showed that 88% of individuals with a penicillin allergy label had their allergy status removed after assessment, indicating that many patients may be inaccurately labelled as allergic. The study was published in The Lancet Primary Care.