Source · Prevention of Future Deaths
Jennifer Tompkins
Ref: 2014-0188
Date: 28 Apr 2014
Coroner: Philip Barlow
Area: London (Inner South)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted potential training issues regarding the correct administration speed of IV medications and a lack of routine documentation when IV infusions are stopped early.
Date
28 Apr 2014
56-day deadline
25 Jun 2014
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted potential training issues regarding the correct administration speed of IV medications and a lack of routine documentation when IV infusions are stopped early.
View full coroner's concerns
the July the Kon;
(ecthne evidence at the inquest was that IV Tazocin should be given iniection: Mr Tindugen's evidence was that he administered this by slow IV minutes. Even allowing for some uncertainty over a period of 7 out in the timings as t0 exact timings, the evidence (as set given above) suggests that the drug was in fact administered quickly: am therefore concerned that there may be training issues relating to the administration of IV medications in this case SoDBoth Dr Kon and Mr Tindugen gave evidence that the IV vancomycin stopped early and before it had been fully administered. infusion was witnesses said that this fact would not be My concern is that both administration routinely documented in the records;and may not be recorded at all. There was no record in this case that the infusion was stopped early. TThe evidence atthe inquest was that Ms Tompkins' death was not caused these matters. However; am concerned that by either of cases any repetition would cause a risk in other
(ecthne evidence at the inquest was that IV Tazocin should be given iniection: Mr Tindugen's evidence was that he administered this by slow IV minutes. Even allowing for some uncertainty over a period of 7 out in the timings as t0 exact timings, the evidence (as set given above) suggests that the drug was in fact administered quickly: am therefore concerned that there may be training issues relating to the administration of IV medications in this case SoDBoth Dr Kon and Mr Tindugen gave evidence that the IV vancomycin stopped early and before it had been fully administered. infusion was witnesses said that this fact would not be My concern is that both administration routinely documented in the records;and may not be recorded at all. There was no record in this case that the infusion was stopped early. TThe evidence atthe inquest was that Ms Tompkins' death was not caused these matters. However; am concerned that by either of cases any repetition would cause a risk in other
Report sections
Investigation and inquest
On 8 July 2011 commenced an investigation into the death of Jennifer Tompkins, age 37 . The investigation concluded at the end of the inquest on 10 April 2014. The narrative conclusion of the inquest was that Jennifer Tompkins suffered fatal allergic anaphylaxis after receiving an intra venous injection of Tazocin on 6 July 2011 at Kings College Hospital:
Circumstances of the death
Ms Tompkins had focal segmental glomerulosclerosis and was undergoing dialysis while awaiting a kidney transplant: On 6 July 2011 she was admitted to KCH under the care of A CT scan suggested that Ms Tompkins had an infected pelvic fluid collection for which she was prescribed IV vancomycin and Tazocin, with cyclizine. These drugs were administered by staff nurse The vancomycin infusion was commenced at 20.07 and the IV cyclizine was given at 20.55 followed by the IV Tazocin After receiving the Tazocin Ms Tompkins suffered allergic anaphylaxis. The cardiac arrest team were called at 21.00 and arrived at 21.04. Sadly, resuscitation attempts were unsuccessful. During the inquest heard from severalwitnesses including and expert evidence from reader in clinical pharmacology at Royal Hallamshire Hospital, Sheffield.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action.
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Report details
- Reference
- 2014-0188
- Date of report
- 28 April 2014
- Coroner
- Philip Barlow
- Coroner area
- London (Inner South)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Jun 2014 (stated in the report).
Sent to
- Kings College Hospital NHS Foundation Trust