Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0313, written 5 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2024 |
|---|---|
| Reference | 2024-0313 |
| Deceased | Gillian Peacock |
| Coroner | James Thompson |
| Coroner area | County Durham and Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive - County Durham & Darlington NHS Foundation Trust 1 CORONER I am James E THOMPSON, Assistant Coroner for the coroner area of County Durham and Darlington 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 15/03/2023 09:42an investigation was commenced into the death of Gillian PEACOCK 16/08/1962 00:00:00. The investigation concluded at the end of the inquest on 05/06/2024 00:00. The conclusion of the inquest was that Gillian Peacock died on 8th March 2023 at Darlington Memorial Hospital. She suffered from a number of health conditions, but significantly atrial fibrillation for which she was prescribed digoxin. She was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithomycin. It was recorded by a hospital pharmacist on 1st March 2023 in her medical notes that the use of these two drugs can cause digoxin toxicity and an alternative drug or monitoring is advised. No alternative drug was prescribed and no monitoring took place until 7th March 2023 where results showed an elevated level of digoxin. Her digoxin was withheld. She had displayed no recognised symptoms of digoxin toxicity during her stay in hospital. She suffered a cardiac arrest on the morning of 8th March 2023 and died. Post Mortem examination could not ascertain a cause of death. The medical evidence cannot on the balance of probabilities determine the contribution of digoxin & clarithomycin to her death.. 4 CIRCUMSTANCES OF THE DEATH Gillian Peacock died on 8th March 2023 at Darlington Memorial Hospital. She suffered from a number of health conditions, but significantly atrial fibrillation for which she was prescribed digoxin. She was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithomycin. It was recorded by a hospital pharmacist on 1st March 2023 in her medical notes that the use of these two drugs can cause digoxin toxicity and an alternative drug or monitoring is advised. No alternative drug was prescribed and no monitoring took place until 7th March 2023 where results showed an elevated level of digoxin. Her digoxin was withheld. She had displayed no recognised symptoms of digoxin toxicity during her stay in hospital. She suffered a cardiac arrest on the morning of 8th March 2023 and died. Post Mortem examination could not ascertain a cause of death. The medical evidence cannot on the balance of probabilities determine the contribution of digoxin & clarithomycin to her death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Gillian Peacock was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithomycin. It was recorded by a hospital pharmacist on 1st March 2023 in her medical notes that the use of these two drugs can cause digoxin toxicity and an alternative drug or monitoring is advised. No alternative drug was prescribed and no monitoring took place until 7th March 2023. The evidence I have heard is that the treating clinicians had not seen the entry in her medical records. This was in part due to the way the entries are displayed in the records and the 'huge' number of entries that are recorded. I heard that now that any pharmacist entries of significance must be verbally passed to a junior doctor involved in the patient's care and in turn passed on at ward meetings to the broader group of staff caring for that patient. I have a concern that the current system does not address the issue of important medical information being recorded in a patient's notes not being accessible in such a way that clinicians can see and if necessary act on it. The use of verbal handovers does not in my view fully address my concern that crucial medical information should be recorded in a patient's medical records in such a way that relevant information is visible to those involved in care. In addition, that it can be accessed immediately without reliance on the verbal passing of information from one member of the treating team to another. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by July 31, 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Care Quality Commission who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 05/06/2024 James E THOMPSON Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX Our Ref: GPEACOCKINQ1350 E-mail: 29th July 2024 James Thompson, Assistant HM Coroner, County Durham Dear Mr Thompson, Re: Gillian Peacock We are writing in response to your request for the Trust to take action in relation to your concerns following the inquest held on 5th June 2024. Your concern was that current processes mean that important medical information being recorded in a patient's notes is not accessible in such a way that clinicians can see, and if necessary act, on it. You suggested that this was in part due to the way the entries are displayed in the records and the 'huge' number of entries that are recorded. The Trust would like to offer its sincere condolences to Gillian’s family for their loss. We take very seriously the concerns which you have raised and have provided a response below. Electronic patient records (EPR) bring with them significant benefits in that notes are legible, structured and individual entries are significantly easier to locate than in paper notes. As you heard at the inquest the pharmacy entry in Mrs Peacocks notes was made on 1st March 2023 and in additon to the documented note was also verbally handed over to the medical team. Figure 1 below shows the entry in the documentation list and Figure 2 shows the detail of the pharmacy entry. Figure 1 – Pharmacy Note in Documentation List Figure 2 – Detail of Pharmacy Entry in Documentation Whilst the Trust acknowledges the suggestion that some form of alert would have been of benefit we would like to highlight that there needs to be a judicious use of alerts. In one month there are circa 250,000 alerts fired in the EPR. In the period 23 Jun – 24 Jul 2024 44% (109,023 of 247,365) of all alerts fired were related to medications and prescribing. Figure 3 – Number of Alerts Fired by Day Figure 4 – Number of Alerts by Category Alerts in the EPR are referred to as clinical decision support and are a tool that helps clinicians in decision making by generating clinical alerts to supplement their previous knowledge and experience. However a large number of alerts can result in alert fatigue. (2020) define this as: ‘the mental state of alerts consuming too much time and mental energy, which often results in relevant alerts being overridden unjustifiably, along with clinically irrelevant ones. Consequently, clinicians become less responsive to important alerts, which opens the door to medication errors’ There are 4 levels of alerts relating to drug to drug interactions that are imported into Cerner EPR from the Multum drug interactions database: Level 1 Major contraindicated - This interaction poses a major threat to the patient’s health and is the highest severity level. This requires a prescriber to either discontinue the pre-existing, interacting medication order, or override the alert with a documented clinical reason. Level 2 Major - This interaction poses a major threat to the patient’s health and is not recommended. This category includes interactions where additional contraception may be needed, an interval adjustment, dose adjustment or close monitoring is recommended. Level 3 Moderate - The interaction poses a moderate threat to the patient’s health and should be evaluated. Level 4 Minor – This interaction poses a minimal threat to the patient’s health. The EPR at CDDFT has Level 1 alerts activated within the system and includes approximately 11200 different drug-drug interactions. The interaction between digoxin and clarithromycin is classed as a Major (level 2) interaction where additional monitoring or dose adjustment would be appropriate. In line with other organisations utilising this software, level 2 and below interactions are not activated as prescriber alerts within the system due to the risks of alert fatigue described above. If level 2 drug-drug interaction alerts were activated this would include a further 23400 drug-drug interaction combinations. Having taken into consideration your concerns the Trust is convening a multi-disciplinary, cross speciality group led by the Chief Pharmacist to review all Major (level 2) drug to drug interactions to review whether any are appropriate to activate a prescriber alert. Conclusion We trust that the responses detailed in this letter are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries. Yours sincerely Executive Director of Nursing Executive Medical Director cc. , CEO , Associate Director of Nursing, Patient Safety and CNIO
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