Oriel Vasey died on 5 March 2025 at Sunderland Royal Hospital after developing a pressure area on her sacrum which deteriorated and resulted in sepsis.

The inquest found a form completed by a mental health nurse for ICB and local authority funding and placement arrangements contained information relevant to a previous service user who had a penicillin allergy.

As a result of the information being added to Mrs Vasey's clinical record doctors repeatedly ruled out prescribing penicillin when her infection was identified, although the coroner said she could find evidence that this would have changed the outcome.

A North East and North Cumbria ICB spokesperson said: ‘We are saddened by the death of Mrs Vasey, and our thoughts are very much with her family and friends.

‘We take all concerns very seriously and we are working with our NHS partners to carefully review the coroner's findings.'