Source · Prevention of Future Deaths

Jennifer Birch

Ref: 2026-0299 Date: 20 May 2026 Coroner: Laurinda Bower Area: Nottingham City & Nottinghamshire Responses identified: 2 / 2 View PDF

The Trust demonstrated a lack of an "inquiring mind" culture, leading to failures in capturing and retaining crucial clinical evidence following incidents. Concerns were also raised about the delayed roll-out of the Penicillin Allergy De-Labelling Pathway, which would reduce the use of riskier alternative antibiotics.

Date 20 May 2026

56-day deadline 8 Oct 2026 est.

Responses identified 2 of 2

Coroner's concerns

AI summary

View full coroner's concerns

(NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour

The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.

My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart.

This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).

The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.

(ICB) Roll out of the Penicillin Allery De-Labelling Pathway

Teicoplanin carries a rare but recognised risk of severe anaphylaxis and reaction occurring in an estimated 0.1-1% of cases. Teicoplanin is often used as an alternative to penicillin for patients who report penicillin allergy. The risk of serious complications is greater in teicoplanin than many other forms of antibiotic (NAP6). It has been described as “an emerging problem in the anaesthetic allergy clinic” (British Journal of Anaesthesia, 2015).

Jen was administered teicoplanin in the peri-operative period because the recommended antibiotic for her elective procedure, Flucloxacillin, is from the same antibiotic family as penicillin, and Jen’s medical records reported an allergy to penicillin in the form of a rash as a baby.

The use of teicoplanin in this case was entirely appropriate given Jen’s allergy warning, but it did expose her to a risk of severe anaphylaxis, which materialised and caused her death. In the months following Jen’s death, some Trusts have rolled out an inpatient initiative to seek to de-label penicillin allergy from patient medical records where risk stratification determines that the patient does not have a true allergy to penicillin. The SPACE study established that up to 10% of the population carries documented penicillin allergy but over 90% of these are inaccurate. False labels have been shown to increase antibiotic resistance, higher surgical site infections, longer hospital stays, as well as exposing patients to unnecessary complications associated with second-line antibiotics.

One local Trust, Doncaster and Bassetlaw NHS Trust, has already rolled out an inpatient PADL pathway. The SPACE study proved it is clinically safe and effective for non-allergy healthcare professionals to use approved risk stratification and direct oral penicillin challenges for low-risk patients, ensuring the burden for this pathway does not impact on the often-small secondary care allergy service.

Does the ICB plan to commission this pathway across all local Trusts? At present, NUH does not offer this pathway.

Responses

2 respondents

ICB

20 May 2026 PDF

Action Planned

The ICB is committed to commissioning an appropriate penicillin allergy de-labelling service and has begun work to develop a stakeholder group that will meet to discuss the most suitable pathway for implementation across the population. (AI summary)

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Dear Miss Bower JENNIFER SUSAN BIRCH: REGULATION 28 REPORT RESPONSE I am writing in response to the Regulation 28 Report dated 20 May 2026, following the inquest into the death of Jennifer Susan Birch. Nottingham and Nottinghamshire Integrated Care Board sincerely apologises to the family of Jennifer Susan Birch for the incredibly sad circumstances surrounding her death. We acknowledge that over 95% of penicillin allergy labels are incorrect leading to the avoidable use of broad spectrum antibiotics, increased antimicrobial resistance, increased mortality and morbidity. As an ICB we are committed to understanding how to commission an appropriate service to challenge incorrect diagnosis of penicillin allergy. Penicillin allergy delabelling is a clear example of upstream, preventative intervention that:
• Enables whole pathway commissioning across primary, secondary and specialist care.
• Supports population health management.
• Aligns with NHSE ambition to shift from sickness to prevention, hospital to community and deliver integrated care. However, there is also a lot of work that needs to be done nationally to undo the perceptions that the population have related to penicillin allergy and the perceived risks from patients in readministering penicillins when they have received a penicillin allergy label. Consequently, commissioning alone will not solve the problem. NHSE are currently supporting the understanding of when a person is delabelled the infrastructure needed to ensure that label is appropriately recorded. Conversations are ongoing related to education and training health care professionals, myth busters for the population related to penicillin allergy, coding, wider digital transformation, information governance and clinical governance. However, it is important that we give patients their own personal correct information Key Rationale for Delabelling/Case for change
• Reduces Antimicrobial Resistance (AMR): When penicillin is unavailable, doctors prescribe broader-spectrum alternatives (like fluoroquinolones or macrolides). This unnecessary use fuels the growth of drug-resistant "superbugs".
• Improves Clinical Outcomes: Patients without access to first-line penicillins face a higher risk of hospital admission, hospital-acquired infections, such as MRSA and Clostridium difficile (often triggered by broad-spectrum drugs destroying healthy gut bacteria) and longer length of stay. There is also evidence of increased mortality in those with a penicillin allergy label.

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• Lowers Healthcare Costs: Broad-spectrum antibiotics are significantly more expensive than standard penicillins. Removing the incorrect label reduces pharmacy expenditures and shortens excess hospital bed stays.
• Better Surgical Recovery: Surgical patients carrying a penicillin allergy label face a documented increase in surgical site infections because they miss out on optimal, targeted antibiotic prophylaxis.
• Promotes Antimicrobial Stewardship: Delabeling initiatives are a core target of national public health organizations (such as the UK's 5-year antimicrobial resistance plan) aimed at optimizing antibiotic use across healthcare systems. How Delabeling Works The process uses risk-stratification algorithms combined with validated direct oral challenges or skin tests. By safely confirming who is not allergic, non-allergist clinicians (like pharmacists and medics) can clear a patient's medical records, so they have access to the safest, most effective treatments in the future Stakeholders To enable a penicillin allergy delabelling program to be embedded effectively across a provider organisation, all key professionals who are essential for its success need to be included and engaged with. We will use existing pharmacy, antimicrobial stewardship teams, primary care and allergy services to develop a model that will work for the population of Nottingham and Nottinghamshire. We hope to be able to provide support to the NHSE program to evidence what works well. Nottingham and Nottinghamshire ICB has begun work on developing a stakeholder group that will meet to discuss the most appropriate pathway to facilitate delabelling in the population. With up to 10% of the population affected, it would not be possible for allergy services alone to facilitate this and there will need to be a focused approach with those at highest risk targeted first.

Nottingham University Hospitals NHS Trust NHS Trust

16 Jul 2026 PDF

Action Taken

The Trust has undertaken significant work on its Duty of Candour, including staff re-engagement and an educational package, and implemented a new internal Learning Review Policy in December 2025. It also developed and delivered a new policy and education sessions for staff on equipment identification and quarantine. (AI summary)

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Dear Miss Bower Inquest: Jennifer Susan Birch - Prevention of Future Death Report [PFDR] Response I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Death Notice issued on 20 May following the sad death of Jennifer Susan Birch. May I begin with offering my sincerest condolences to Jen’s family for their loss. I am deeply sorry for the missed opportunities and issues highlighted during the Inquest. The concerns you have raised have been taken extremely seriously. Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Jen. The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees with Executive oversight - Committees of our Board will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.

Report sections

Investigation and inquest

On 15 April 2025 I commenced an investigation into the death of Jennifer Susan BIRCH aged 27. The investigation concluded at the end of the inquest on 20 May 2026. The conclusion of the inquest was that:

Jen died as a result of a rare anaphylactic response to teicoplanin.

Circumstances of the death

Jennifer Susan Birch died on 11 April 2025, at the Queens Medical Centre, Nottingham, as a result of an hypoxic brain injury, sustained during a period of anaphylaxis in response to the administration of intravenous prophylactic antibiotic, teicoplanin, in the peri-operative period of an elective procedure performed on 8 April 2025.

During the peri-operative anaesthetic emergency, a 2222 call was not put out, contrary to local guidance. While this probably led to some omissions in the care that could have been provided to Jen, it has not been possible to determine whether such omissions have more than minimally contributed to her death.

Action should be taken

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

Copies sent to

I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles]

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2026-0299
Date of report: 20 May 2026
Coroner: Laurinda Bower
Coroner area: Nottingham City & Nottinghamshire

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Oct 2026 (estimated).

Sent to

Nottingham and Nottinghamshire Integrated Care Board

Nottingham University Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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