Source · Prevention of Future Deaths
Samantha Singh
Ref: 2021-0225
Date: 2 Jul 2021
Coroner: Graeme Irvine
Area: East London
Responses identified: 0 / 2
View PDF
A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no allergy clinic referral or follow-up was offered.
Date
2 Jul 2021
56-day deadline
27 Aug 2021
Responses identified
0 of 2
Coroner's concerns
A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no allergy clinic referral or follow-up was offered.
View full coroner's concerns
(1) Results of Miss Singh's RAST test were wrongly categorised by the surgery as normal. As such, no further action was indicated by the surgery. It was only Ms Singh's perseverance that led to a follow-up appointment being arranged to discuss the results with her GP where the mistake was discovered (2) At a GP appointment on 27 November 2019, Miss Singh was prescribed a single EpiPen, NICE guidance at the time indicated that no fewer than two epi-pens should be prescribed to a patient_ (3) Following the appointment on 27 November 2019 Miss Singh was not referred to allergy clinic or offered a follow-up appointment to address issues arising from her allergy diagnosis_
Report sections
Investigation and inquest
On 297H July 2020 | commenced an investigation into the death of Samantha Singh, 26 years old, The investigation concluded at the end of the inquest on 22nd June 2021 . conclusion of the inquest was cause of death: 1a Anaphylactic shock 1b Allergy to nuts_ acting Jukpga The
A short form conclusion of accidental death was arrived at
A short form conclusion of accidental death was arrived at
Circumstances of the death
Miss Samantha Singh attended her general practitioner's surgery in November 2019 to raise a concern regarding her suspicion that she suffered from a nut allergy. Following a RAST test Miss Singh was assessed to suffer from a mixed nut allergy, she was prescribed an EpiPen_ On 25 2020 Miss Singh became unwell at home and suffered a cardiac arrest attributable to anaphylactic shock: Despite best efforts of her family and emergency services she could not be resuscitated_
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action_
Similar PFD reports
Related inquiry recommendations
Scottish Hospitals Inquiry
Training for IPC professionals engineers and clinicians
Scottish Hospitals Inquiry
IPC role specifications and staffing levels
Southport Inquiry
Autism spectrum disorder police training
Southport Inquiry
Prevent training on online activity assessment
Southport Inquiry
Neurodiversity training for Prevent practitioners
Southport Inquiry
Balancing vulnerability with professional curiosity
Southport Inquiry
Sharing information about closed Prevent referrals
Southport Inquiry
Prevent Supervisor training on closure decisions
Southport Inquiry
Prevent referral training for organisations
Southport Inquiry
Taxi driver duty to report criminal activity
Report details
- Reference
- 2021-0225
- Date of report
- 2 July 2021
- Coroner
- Graeme Irvine
- Coroner area
- East London
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Aug 2021.
Sent to
- Hainault Surgery
- SMA Medical Practice