Sharon Robinson

Medical Director’s Unit 
Service Delivery Office 
Airedale General Hospital 
Skipton Road, Steeton 
Keighley 
West Yorkshire 
BD20 6TD 
Web: www.airedale-trust.nhs.uk 

5 January 2022 

Dr Anthony Howard 
HM Assistant Coroner for  
West Yorkshire Coroner Area 

Via email 

Dear Sir 

I write to set out the Trust’s response to the learned Coroner’s Regulation 28 Prevention of 
Future Deaths Report dated 16 November 2021.  

It  is  noted  that  the  Coroner  conducted  an  investigation  into  the  death  of  Sharon-Anne 
Robinson and concluded the inquest with the medical cause of death being recorded as: 

1a Hypoxic Brain Injury 
1b Cardiac Arrest 
1c Treated chest infection (with amoxicillin anaphylaxis) 

It is noted that the inquest was concluded with a narrative conclusion which states that: 

“Sharon Robinson died on the 7th February, 2019 at Airedale Hospital as a result of 
administration  of  an  antibiotic  on  the  27  January  which  induced  an  anaphylactic 
reaction.” 

It is further noted that the Coroner sets out his concern in the PFD report as follows: 

“There  is  a  concern  that  when  a  patient  may  have  a  sensitive  [sic]  to  anti-biotic 
despite the low risk, this will be ignored and anti-biotic be given in any event.” 

I would firstly like to pass on my sincere condolences to Mrs Robinson’s family for their loss 
and to make clear that we have taken this case very seriously and wish to learn as much as 
we can from these tragic events. We started this process off when we conducted an internal 
investigation  into  the  death  and,  at  the  time,  set  out  a  series  of  actions  in  response  which 
were included in the Trust’s Serious Incident Report dated 30th April 2019. This report was 
submitted  to  the  CCG  and  confirmation  received  in  relation  to  the  subsequent  review  of 
learning and actions. 

I would then like to address the suggestion that a patient’s sensitivity to an antibiotic would 
be ‘ignored’ and an antibiotic given in any event.  In the case of Mrs Robinson, the Trust’s 
evidence  given  at  inquest  was  that  Mrs  Robinson’s  recorded  allergy  to  Penicillin  was  not 
‘ignored’.  It  was  carefully  considered  when  the  treating  clinician  exercised  their  clinical 
decision  making  around  whether  or  not  it  would  be  appropriate  and  safe  to  administer 
Amoxicillin  (Penicillin-based  antibiotic)  for  a  Lower  Respiratory  Tract  Infection  (‘LRTI’)  in 
January 2019.  The Trust’s evidence was that, before deciding to prescribe Amoxicillin, the 
patient  had  reported  to  clinical  staff  that,  notwithstanding  the  ‘allergy  alert’  on  her  file,  she 

Associated Teaching Hospital of the  
University of Leeds School of Medicine 

 
 
 
 
 
 had  successfully  been  treated  with  Amoxicillin  on  many  previous  occasions  without  any 
adverse  reaction.  The  treating  clinician  was  able  to  corroborate  this  point  by  reference  to 
medical  records  (as  recent  as  September  2018),  which  confirmed  that  Mrs  Robinson  had 
been discharged on a course of Amoxicillin for the same clinical condition and had reported 
no adverse reaction to the same.  It was the Trust’s evidence that whilst a medication allergy 
should always be elicited, recorded and carefully considered, it is right to explore the nature 
of  an  allergy  (signs,  symptoms  and  severity)  in  line  with  NICE  guidance  CG183.    This  is 
even  more  so  in  circumstances  where  the  condition  in  question  is  best  treated  by  the 
antibiotic  subject  to  the  allergy  alert,  as  was  the  situation  in  Mrs  Robinson’s  case.  The 
Trust’s  evidence  at  inquest  was  that  allergies  are  often  relative,  stem  from  childhood,  are 
often not experienced again in later life and do not always pose a major threat.  

I thought it was appropriate to make it plain in this response that this was not a case of the 
treating  clinician  prescribing  a  medication  in  ignorance  of  an  allergy.  It  is  a  case  where  a 
conscious  decision  was  made to  administer  the  Amoxicillin  to  the  patient  after  it  had  been 
confirmed by the patient that she had not suffered any adverse reaction to Amoxicillin over 
many years, which, as I have set out, was corroborated by reference to her medical records 
stating  over  40  courses  of  penicillin-based  antibiotics  prescribed  in  the  community  since 
2003.  [It  is  also  a  case  that  the  Trust’s  antimicrobial  policy  was  followed  by  the  treating 
clinician in relation to antibiotic choice and the allergy history.]  

It would, therefore, appear to me that the Coroner’s concern is targeted at whether or not it is 
appropriate to administer an antibiotic to a patient in the presence of a known or suspected 
allergy  to  an  ingredient  within  that  particular  antibiotic  in  any  circumstances,  and  this  is 
therefore the primary point we have sought to consider and address as an organisation, in 
order to provide some assurance to ourselves and the learned Coroner.  

In order to  do  so, I  am pleased  to report  on  some  of the  activities which have taken  place 
since receipt of the Regulation 28 PFD report, as follows: 

•  Case  discussed  at  the  Senior  Medical  Leadership  Group  meeting.  This  includes  all 
Clinical Directors and Divisional Medical Directors within Airedale NHS Foundation Trust.  

•  Case discussed at the Bradford District and Craven Medical Directors Meeting – this is an 
external meeting and the purpose of discussing the case in this forum was to ascertain a 
wider  view  which  encompasses  other  Acute,  Mental  Health  and  Community  Trust  and 
Primary Care medical directors – so a wide audience to test the thinking and challenges 
this  poses in ensuring  each patient  is  assessed  on  their  merit  and  there is  a consistent 
approach across Bradford & Airedale. 

•  Chief  Pharmacist  and  Executive  Medical  Director  are  working  to  align  the  approach  for 
Bradford Teaching Hospitals and Airedale Hospitals, which will be overseen by the Drug 
and Therapeutics Committee. This includes revision of the Antimicrobial Policy – to build 
in best evidence-based practice with experts to implement safe patient care. 

  The Chief Pharmacist sits on regional fora in West Yorkshire and Harrogate where again 

the Trust approach is being considered. 

  The Trust Antimicrobial Pharmacist has discussed this case at the Yorkshire and Humber 

Antimicrobial Pharmacists Network. 

The  Trust  recognises  the  Coroner’s  concern  that  there  is  a  risk  of  a  prescription  of  a 
medication to a patient where there is a documented allergy. In wider discussions with senior 
clinicians  within  and  outwith  the  Trust,  it  has  also  heard  a  concern  that  there  are 

Associated Teaching Hospital of the  
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 circumstances  in  which  allergies  are  recorded  inaccurately  in  relation  to  medication  side 
effects  (such  as  due  to  nausea/  diarrhoea)  and  where  a  risk  based  discussion  (clearly 
documented  and made at  senior  level)  might  be  appropriate,  and prevents  the  exceptional 
circumstance in which a medication might be withheld and alternatives may be non-existent 
or have more intrinsic risks of other toxicities.  

The Trust is, therefore, seeking ongoing wider engagement with other healthcare providers 
to understand how this risk is effectively managed in those organisations and ensuring that 
HM Coroner’s recommendations are visible in their own organisations. 

I do hope that the information provided in this response has been of help and that it sets out 
in context the thought  processes  surrounding  and actions  taken  in response  to  this  clinical 
incident. I will update HM Coroner in relation to the update of our Antimicrobial Policy, once 
the wider alignment with acute Trusts is concluded.  

Yours sincerely 

Executive Medical Director  

Associated Teaching Hospital of the  
University of Leeds School of Medicine