CORONER Dominic Mulligan has ruled the March 2008 death of a 68-year old woman at Northam Hospital accidental, despite 14 notes alerting hospital staff to her condition.
Carol Whiteford was admitted to the hospital for a cataract operation.
She was given a 250 milligrams tablet of Diamox and within 20 minutes complained of shortness of breath.
Within two hours she was dead.
The tablet contained sulphon amides and was administered even though Mrs Whiteford's medical file contained at least 14 documents in which her allergy to sulphur-based medications was recorded.
Mrs Whiteford also wore a red-bracelet on her wrist indicating she had allergies.
After an inquest, Mr Mulligan concluded her death was owing to misadventure.
He said Mrs Whiteford was placed at "unnecessary risk" as her surgeon had not read her hospital file, was not aware of her allergy to sulphur nor the importance of her wearing the red bracelet.
"This case highlights the need for precision when describing a patient's allergy," Mr Mulligan said.
Earlier this year, the inquest was told Mrs Whiteford, within 20 minutes of being given the pill, complained of shortness of breath.
Within two hours she was dead.
Previous concerns at Northam Hospital have seen three doctors suspended after five patients died following discharge.
In March, WA's Department of Health said three doctors would be referred to the Medical Board of Australia following an investigation by chief medical officer Gary Geelhoed.
