A GREAT grandmother died after she was given drugs she was allergic to in hospital following a medical records blunder, an inquest heard.

Doctors at Burnley General Hospital prescribed Beatrice Sagar paracetamol and an epilepsy drug after her ‘incomplete’ notes failed to record she had previously had a serious reaction to them, the town’s coroner’s court was told.

Health chiefs said they had carried out a complete overhaul of the way medical records are kept within East Lancashire Hospitals NHS Trust following the death in May 2005 of Mrs Sagar.

Her family said that they were pleased with the changes implemented as a result of the 86-year-old’s death.

The inquest heard Mrs Sagar was given paracetamol and an epilepsy drug to stabilise her condition, on the advice of a specialist, after she was admitted to hospital following a suspected seizure.

But East Lancashire coroner Richard Taylor said if the records had been complete they would have noted that Mrs Sagar had suffered serious reactions to both drugs on previous occasions.

The inquest heard that Mrs Sagar, who lived at Higher Reedley Farm, Reedley Drive, later contracted toxic epidermal necrolysis which contributed to her death on May 15 from bronch-pneumonia.

Mr Taylor said Mrs Sagar had been given paracetamol on May 4 or 5 and the epilepsy drug on May 4 and 8, and had then suffered an allergic or hyposensitive reaction to both substances over the next few days.

Neither the GP notes nor the hospital records included any reference to her sensitivity to the drugs, which had led a consultant to make a decision to administer them, the coroner added following a week-long hearing at Burnley Town Hall.

Earlier he said: “I desperately hope this type of incident will not reoccur and that no doctor or consultant will have to make a diagnosis without full and accurate records being available and to hand.”

Mr Taylor said he was satisfied with the reassurances he had received from East Lancashire Hospitals NHS Trust, during the course of the inquest, that steps had been taken to prevent similar cases emerging in future.

The coroner praised the conduct of Mrs Sagar’s family, who had wanted the inquest to discover how exactly she had died and whether such incidents could be avoided for other hospital patients, and medical experts who had assisted with his inquiries.

Mr Taylor recorded a narrative verdict which noted the circumstances of her death and the central issue with the medication.

Following the inquest one of Mrs Sagar’s daughter, Marjorie Owens, praised the help and assistance which her mother had received from doctors and nurses at the hospital.

She said: “Mum was receiving a lot of good nursing and medical care over the last few years. It was just when it came to the records that things went wrong.”

Mrs Owens was also supportive of the care her mother received at the former Leeds Road surgery, where she was previously a patient.

But she believed difficulties with records may have occurred when the practice joined other surgeries at the larger Yarnspinners health centre in Nelson.

Barbara Martinus, another daughter who also accompanied Mrs Sagar’s husband Herbert, 91, to the inquest, said she was happy that systems were in the process of being changed at the hospital.

She added: “But there is no evidence that medical staff are going to carry out the checks which are there. They are under pressure all the time and they do not do all the checks that they should do.”

After the hearing, Peter Weller, East Lancashire Hospitals NHS Trust’s associate director of patient safety, said: “Following the conclusion of the inquest the trust would like to express our condolences to the Sagar family over the death of Beatrice Sagar.

“The trust has always co-operated with the coroner’s investigation and of course accepts the coroner’s verdict in this matter.

“Since this tragic incident the trust has endeavoured to improve systems relating to the retrieval of patient medical records to allow our doctors and nurses to have an accurate and up-to-date picture as possible of all patients’ medical conditions and where relevant, allergies to medication.

“We hope the changes and improvements made will prevent ,as far as possible, such a tragedy occurring again.”

Mrs Sagar had three children, seven grandchildren and three great-grandchildren.