Jennifer Birch

PRIVATE AND CONFIDENTIAL 
Miss Laurinda Bower   
HM Area Coroner for Nottingham City & Nottinghamshire 

Sir John Robinson House 
Sir John Robinson Way 
Arnold 
Nottingham 
NG5 6DA 

30 July 2026 

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. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  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. 

Yours sincerely 

Executive Director of Outcomes (Medical) 
Derby and Derbyshire ICB, Lincolnshire ICB, Nottingham and Nottinghamshire ICB

Please ask for the Medical Director’s Personal Assistant   

16 July 2026 

PRIVATE & CONFIDENTIAL 
Miss Laurinder Bower 
HM Area Coroner for Nottingham City and Nottinghamshire 
HM Coroner’s Court 
The Council House 
Market Square 
Nottingham NG1 2DT 

Dear Miss Bower 

Medical Director’s Office 
Trust HQ, 3rd Floor 
City Hospital campus 
Hucknall Road 
Nottingham 
NG5 1PB 

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.  

Yours sincerely 

Medical Director and Responsible Officer 

Enc 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Concerns identified through the PFD 

The coroner remained concerned that there were outstanding matters giving rise to 
concern that future deaths will occur, as follows:  

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

candour 

2.  (ICB) Roll out of the Penicillin Allergy De-Labelling Pathway 

Response to the concerns identified through the PFDR 

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

Duty of Candour (DoC) is both a professional obligation for healthcare professionals, 
whenever there are any problems in care, and a statutory obligation for the Trust in 
the event of any incidents of significant harm.  

Good practice in candour requires staff and the organisation to be open and honest 
with patients, families and the organisation when things go wrong.  This professional 
duty is regularly discharged in clinical care when there are low or no harm events, (for 
example  apologising  for  an  extended  wait,  or  that  a  procedure  has  caused  a  mild 
bruise).  

Statutory Duty of Candour in accordance with Regulation 20 of the Health and Social 
Care Act 2008 (Regulated Activities) Regulations 2014 requires registered providers 
to ensure the timely reporting of incidents, sharing of facts with patients and families 
at the earliest opportunity, apologising when things go wrong and enabling effective 
review and organisational learning. This requires a sufficiently thorough and enquiring 
approach  to  understanding  the  facts,  explaining  what  is  known,  identifying  what 
remains uncertain, and ensuring that appropriate learning and action follow.  

The Trust acknowledges that a culture of openness, timely reporting, and proactive 
evidence capture is fundamental to learning from patient safety events and improving 
outcomes. 

The Trust fully recognises the coroner’s concern that: 

•  Failure to submit a Datix report on the day of the event delayed escalation and 

appropriate response actions.  

•  This contributed to:  

  Failure to quarantine potentially faulty medical equipment 
  Failure to secure and download device data prior to overwrite/loss 
  Failure  to  retain  some  contemporaneous  clinical  documentation, 

including the anaesthetic chart  

 
 
 
 
 
 
 
 
 
 
 
 The  Trust  also  acknowledges  the  coroner’s  wider  observation  that  this  issue  is  not 
isolated to one specific Department or incident but reflects a recurring, Trust-wide risk 
relating to the retention of evidence following clinical events.  

Historic  examples  referenced,  including  retention  of  placentas,  CTG  traces,  and 
medical device data, demonstrate that this is a systemic issue requiring a coordinated 
organisational response.  

Other relevant cases of note: 

•  Placentas  disposed  of  following  neonatal  harm;  PFD  report  issued  2021 -            

Q Parker.  

•  Lost CTG traces – no specific case references.  
•  Cardiology  medical  devices  not  being  retained/quarantined/inspected  in  a 
timely fashion leading to relevant data being overwritten or devices destroyed.  

The Trust accepts that: 

•  There have been inconsistencies in the timely identification, preservation, and 

retention of critical evidence following incidents. 

•  These  gaps  have,  in  some  cases,  hindered  investigations  and  delayed  the 

establishment of factual findings. 

•  The underlying issue is both:  

  Cultural – absence of a consistently applied “forensic inquiring mind” at 

the point of care. 

  Systemic  –  lack  of  sufficiently  embedded  processes  and  prompts  to 

ensure immediate evidence capture. 

The Trust recognises that this is particularly high risk where medical devices are not 
networked or cloud-based, meaning that data may be lost when devices are powered 
down or reused.   

The Trust has initiated a programme of system and culture improvement to address 
these concerns. 

i.  Strengthening Policy Framework:  

Both  the  Medical  Device  Governance  and  Management  Policy  and  Safety  Events 
Reporting and Management Policy have been explicitly strengthened in relation to the 
immediate  reporting  of  incidents  and  the  retention  and  quarantine  of  devices  and 
associated  data.    These  documents  are  undergoing  ratification  through  Trust 
governance  channels  prior  to  publication  and  are  expected  at  Medical  Devices 
Management Committee in September 2026. In the interim, the processes described 
in the policy are already being enacted when relevant incidents are reported.  

 
 
 
 
 
 
 
 ii. 

Introduction of new Standard Operating Procedures (SOPs) 

Two new SOPs have been developed to provide clear, actionable guidance: 

•  Clinical user actions following medical device safety events (GGCM068). 
•  Medical Equipment Incident Management and Procurement actions following 

device safety events (CLCGP004). 

These set out immediate steps to secure devices and preserve data for investigation, 
addressing  the  gap  identified  in  this  case.  They  also  contain  guidance  on  secure 
storage  of  such  equipment  and  further  testing  or  analysis  processes,  including 
engagement with the manufacturer for interrogation and checking. Governance sign 
off is expected in September 2026. These new policies will then be disseminated via 
PSG  and  MDMC  routes  to  Care  Groups  for  wider  sharing.  The  delivery  of  these 
policies will be overseen by PSG and MDMC. 

iii.  Visual Prompts and Frontline Support  

Posters  and  visual  aids  for  clinical  areas  (including  theatres)  will  be  produced  to 
reinforce when to act, what actions to take and reinforce why evidence preservation is 
critical, including who to contact for additional support if needed. These visual aids are 
intended to support real-time decision-making at the point of care. It is expected that 
that they will be available in October 2026 and can be shared with the coroner when 
available. 

iv.  Training and Workforce Development 

A Trust-wide programme of enhanced training is being developed to:  

Improve understanding of when and how to report incidents promptly 

• 
•  Promote a learning and candour culture 
•  Reinforce the importance of device quarantine and data preservation 
•  Embed expectations aligned to Duty of Candour and PSIRF principles 
•  Ensure  all  colleagues  are  aware  of  the  need  for  prompt  professional  and 

statutory processes in the event of a patient safety event 

Multiprofessional training is now available for colleagues to book and is running twice 
a month with high take-up such that additional capacity is being planned. There are 
also supporting resources and training videos on the Trust Intranet which have access 
tracking.  Rollout  will  be  monitored  via  the  Duty  of  Candour  Committee.  Additional 
support will be offered to areas with relevant concerns or where there has been limited 
uptake. Key learning and signposting to resources and to dedicated training is now 
included in every new consultant induction. 

v.  Communication and Cultural Reinforcement 

A formal communication plan will accompany the rollout of revised policies and SOPs. 
In  the  interim  messaging  is  being  disseminated  via  Care  Groups  to  reinforce 

 
 
 
 
 
 immediate  expectations  and  promote  a  proactive,  questioning  approach  following 
incidents. 

vi.  Clarity  of  expectation  regarding  individual  professional  standards  and 
accountability for engagement with clinical governance in a learning and 
candour culture.  

QSOG  will  continue  to  ensure  that  individual  accountability  for  engagement  with 
governance  processes  is  clearly  reflected  in  policy  and  processes  of  induction, 
appraisal,  revalidation,  care  group  governance  oversight,  incident  reporting  and 
governance  engagement  (including  FROE)  and,  where  necessary,  professional 
management frameworks. 

Planned Improvements and Assurance 

To ensure sustained improvement, the Trust is implementing the following:  

•  Reviewing opportunities to minimise reliance on non-networked devices so that 

device information is more immediately available. 

•  Strengthening digital data capture and retention mechanisms where possible. 
•  Auditing  evidence  retention  practices,  expected  to  occur  at  year  1  following 

policy launch. 

•  Monitoring  compliance  with  incident  reporting  timeliness  and  exploring  the 
rationale for any delays in reporting (accepting that some incidents may not be 
immediately recognisable). 

•  Progress  reporting  into  Patient  Safety  Group  and  Quality  governance 
structures,  including  a  new  digital  quality  platform  for  triangulated  safety 
learning. 

•  Ensuring  that  individual  accountability  for  engagement  with  governance 
processes  is  embedded  via  process  and  policy  and  that  appraisal  provides 
ongoing quality assurance.  

The Trust acknowledges the concerns raised and accepts that inconsistent application 
of an inquiring, forensic mindset has led to failures in evidence capture and retention, 
impacting the quality of incident review on some occasions.  

These  actions  are  intended  to  ensure  that  the  processes  of  discharging  both 
professional and statutory Duty of Candour responses is not treated as a procedural 
requirement  alone,  but  as  an  important  opportunity  to  listen,  investigate,  explain 
openly, and identify learning to improve patient safety.  

 
 
 
 
 
 
 
 2. (ICB) Roll out of the Penicillin Allergy De-Labelling Pathway  

The  Trust  notes  that  this  recommendation  was  addressed  to  the  Integrated  Care 
Board (ICB). Penicillin Allergy De-labelling services are not currently commissioned 
within Nottingham City and Nottinghamshire. 

There  is  increasing  national  recognition  of  the  importance  of  penicillin  allergy 
assessment and de-labelling programs as part of antimicrobial stewardship strategies. 
Evidence indicates that while approximately 10% of patients report a penicillin allergy, 
the vast majority are not truly allergic when formally assessed. Inaccurate penicillin 
allergy labels can result in the use of broader-spectrum or less effective antibiotics, 
which may contribute to poorer clinical outcomes, antimicrobial resistance, increased 
healthcare costs, and longer hospital stays. 

National  guidance  from  organisations  including  NHS  England,  UK  Health  Security 
Agency  (UKHSA),  the  British  Society  for  Allergy  and  Clinical  Immunology  (BSACI), 
and the National Institute for Health and Care Excellence (NICE) supports the accurate 
identification  and  management  of  drug  allergies  and  promotes  antimicrobial 
stewardship  through  the  use  of  the  most  appropriate  antibiotic  therapy.  Penicillin 
allergy de-labelling programs are increasingly recognised as an important component 
of this work. 

Senior colleagues within NUH Allergy, Microbiology and Pharmacy Services are aware 
of  the  coroner’s  recommendation  and  are  supportive  of  developments  that  would 
improve access to penicillin allergy assessment and de-labelling pathways for the local 
population. The Trust would welcome opportunities to work collaboratively with system 
partners, including the ICB, to explore the development of such services, subject to 
appropriate  commissioning  arrangements,  workforce  capacity  and  sustainable 
resourcing. 

In the meantime, the Trust will continue to support good clinical practice through robust 
antimicrobial  stewardship  processes,  specialist  allergy  advice  where  available,  and 
ongoing  education  of  clinical  staff  regarding  the  assessment  and  documentation  of 
reported drug allergies. 

In the interim, pharmacy and microbiology teams routinely support clinical teams with 
antimicrobial  advice  to  offer  antibiotic  allergic  patients  the  most  effective  antibiotic 
choices with the lowest potential risk of cross reactivity, side effects and resistance. 
When  there are patients  who have  recurrent  infections but uncertain  allergy  status, 
they can be individually referred to the allergy and immunology service. 

 
 Summary 

The  actions  outlined  above  are  intended  to  address  the  concerns  identified  in  the 
Prevention of Future Deaths report. 

I  hope  this  response  provides  both  you  and  the  family  reassurance  of  the  Trust’s 
commitment to learning from this case and to strengthening the safety and quality.