The coroner says the mistake led to worse care for Oriel Vasey
A mistake on a medical form led to the “sub-optimal care” of an 88-year-old sepsis patient, a coroner has said.
Assistant coroner for Sunderland Abigail Combes wrote to the North East and North Cumbria Integrated Care Board (ICB) about the handling of a form which mistakenly noted that Oriel Vasey had a penicillin allergy.
The coroner said she could find “no evidence” this mistake had caused Vasey’s death but it had led to her receiving worse care.
The ICB said it was saddened by Vasey’s death. “We take all concerns very seriously and we are working with our NHS partners to carefully review the coroner’s findings,” it said.
Vasey died at Sunderland Royal Hospital on 5 March 2025 after she developed sepsis, according to the coroner’s report.
The report said a form filled in by Vasey’s mental health team mistakenly said she had a penicillin allergy.
Although this form was designed and processed by the ICB for funding purposes only, the error it contained was then added to Vasey’s clinical record and meant she was not given the antibiotic as a first-line treatment in hospital, the coroner said.
‘No role in death’
Combes said Vasey’s family had told clinicians the 88-year-old had faced no adverse effects from the antibiotic in the past, but overturning Vasey’s clinical record based on the recollections of her family would have been too great a risk.
The coroner said she had found no evidence the allergy mistake had played a role in Vasey’s death but nevertheless questioned how a form used for funding purposes could have affected a patient’s clinical record.
She also questioned why the form had asked about the patient’s allergies in the first place, if it was only for financial decision making.
Combes said: “This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again.”
The ICB has until 1 May to respond to the concerns raised by the coroner.
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