Finding into death of Matthew John George

Contributing factors

• Poorly documented and vague history of antibiotic allergies
• Inadequate clarification of nature and severity of past allergic reactions
• Absence of specialist re-consultation before administering flucloxacillin
• Inappropriate setting for antibiotic administration (general ward without cardiac monitoring)
• Failure to implement penicillin challenge protocol
• Use of intravenous rather than intramuscular adrenaline
• Initial hydrocortisone administration instead of immediate adrenaline
• MET call rather than Code Blue activation
• Pre-existing ischaemic heart disease increasing vulnerability to anaphylaxis complications
• Complex co-morbidities including poorly controlled diabetes and renal impairment

Coroner's recommendations

1. Implement readily accessible and accurate electronic records of patients' past adverse reactions to antibiotics and other medications, with prominent alert mechanisms
2. Develop standardised adverse drug reaction (ADR) nomenclature for use across all Australian hospitals
3. Enhance documentation standards to clearly record the nature, severity and timing of allergic reactions
4. Provide clinical education to all staff about beta-lactam hypersensitivity, penicillin-containing agents and cross-reactivity between penicillins and cephalosporins
5. Develop and implement anaphylaxis protocols specifying recognition, classification and treatment standards
6. Reinforce that intramuscular adrenaline (not intravenous) is the first-line treatment for anaphylaxis
7. When penicillin antibiotics are considered despite documented allergy, administer in a critical care environment with full resuscitation facilities, close cardiac monitoring and staff trained in anaphylaxis management
8. Implement penicillin challenge protocols when clinically indicated
9. Ensure Code Blue (not MET call) is initiated for potential antimicrobial adverse drug reactions with hypotension or breathing difficulties
10. Require specialist re-consultation before implementing antibiotic recommendations, not just initial consultation
11. Update hospital policies on allergy documentation and management, particularly for antibiotic desensitisation scenarios
12. Improve communication and documentation of clinical decision-making rationale in cases involving medication allergies
13. Implement medication alert cards and coloured wristbands for patients with documented allergies or adverse reactions
14. Educate patients about clinical risks of inaccurate allergy reporting