A coronial inquest into the death of a 68-year-old woman who was administered a drug she was allergic to at Northam hospital, has found her death arose by misadventure.
Carol Whiteford underwent cataract eye surgery at the hospital in 2008.
She was prescribed medication containing sulphur despite her medical file noting her allergies.
She also wore a red allergy alert bracelet.
Mrs Whiteford suffered anaphylaxis and died in the hospital the next day.
Her doctor Andrew Stewart, who is not employed by the Department of Health, says he was not made aware of the purpose of the bracelet.
In his findings, Coroner Dominic Mulligan recommended surgeons and doctors not employed by the Department agree to minimum standards of practice before being allowed to work at Northam Hospital.
Earlier this year, a State Government review found a lack of co-ordination at the Northam Hospital had contributed to five deaths in the past two years.