Coronial
SAhospital

Coroner's Finding: Davis Tracy-Lee

Deceased

Tracy-Lee Davis

Demographics

34y, female

Date of death

2009-07-08

Finding date

2012-11-15

Cause of death

hypoxic ischaemic encephalopathy due to anaphylactic shock due to antibiotic allergy

AI-generated summary

A 34-year-old woman died from anaphylactic shock to Ceclor, a cephalosporin antibiotic prescribed for otitis externa. Her medical records clearly documented allergies to cephalosporins (Ibilex) and sulphur-based antibiotics, documented at the Europa Medical Centre. Dr G., aged 83, examined the patient and prescribed Ceclor without checking her allergy alert on the computer system. He acknowledged the allergy warning would have been visible when entering notes post-consultation but stated he did not see it. The critical failure was not reviewing the patient's documented allergies before prescribing a cross-reactive antibiotic. This case highlights the importance of systematic allergy verification before any prescription, particularly with computer-flagged alerts, and raises concerns about clinical practice in older practitioners.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practiceemergency medicineintensive careinfectious diseases

Error types

diagnosticmedicationcommunication

Drugs involved

ceclorcefalexinseptrinsulfamethoxazoleibilexilosoneadrenalineatropine

Clinical conditions

otitis externaanaphylactic shockhypoxic ischaemic encephalopathycardiac arrestdrug allergy

Procedures

intubationlife supportbrain perfusion scan

Contributing factors

  • failure to check computer-flagged allergy alert before prescribing
  • prescription of cross-reactive antibiotic (Ceclor) despite documented cephalosporin allergy
  • inadequate pre-prescription review of medical records
  • lack of verbal allergy confirmation documented in notes
  • delayed recognition and treatment of anaphylaxis

Coroner's recommendations

  1. The Minister for Health should raise this case with the Federal Minister for Health to investigate whether there are sufficient doctors to meet the requirements of South Australia
Full text

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