A coroner has called for lessons to be learned after a woman died following surgery at Sheffield's Royal Hallamshire Hospital.
Kay Morrison underwent surgery at the hospital in June 2015 and, although the procedure was carried out correctly, she developed a severe bacterial infection and died of sepsis 10 days later.
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A coroner's report published today reveals she had a history of infections and had previously developed one which proved resistant to certain antibiotics.
But because she had travelled from Cumbria for specialist care, her records were not local and a proper antibiotic history was not obtained, meaning antibiotics were prescribed which it might have been known would prove ineffectual.
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An inquest in December last year concluded that on the balance of probabilities the lack of a proper antibiotic history had contributed to her death.
Christopher Dorries, senior coroner for South Yorkshire, has subsequently written to health secretary Jeremy Hunt and the president of the Royal College of Surgeons, London, recommending that trusts be reminded of the importance of obtaining these files.
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"In my opinion there is a risk that future deaths will occur unless action is taken," he wrote.
Mr Dorries said Sheffield Teaching Hospitals claimed to have since rectified the 'insufficient system' which was in place at the time, but he warned that may not be true for many other hospitals in the country treating patients from outside their locality.