John Cogdon

Group Chief Medical Officer 
The James Cook University Hospital 
Marton Road 
Middlesbrough 
TS4 3BW 

2 January 2025  

Our ref: 

By Email: 

By Post: 

Private & Confidential 
Mr Paul Appleton 
Assistant Coroner  
HM Coroner’s Office 
Middlesbrough Town Hall 
Albert Road 
Middlesbrough 
TS1 2QJ 

Dear Mr Appleton 

Inquest  into  the  death  of  Mr  John  Cogdon  and  response  to  your  Report  to 
Prevent Future Deaths (PFD) 

We write further to the above Inquest and in response to your report made under 
paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 
and 29 of the Coroners (Investigations) Regulations 2013, dated 15 November 2024, 
issued to South Tees Hospitals NHS Foundation Trust. 

You advised that at the hearing on 8 November 2024, you heard evidence that 
different wards and departments within the James Cook University Hospital, 
Middlesbrough utilise different record-keeping and prescribing systems (including 
paper based and electronic based systems).  

Whilst we appreciate the decision to issue a PFD to the Trust is a judicial decision for 
you to make if you feel the threshold has been met, we advised in our letter of 11 
November 2024 that we did not feel that you had been provided with sufficient 
information relating to the Trust’s current position with regard to the electronic 
systems for you to consider. We can only apologise that this information was not 
available at the Inquest.  

 
 
 
 
 
 
 
 
 
 
 
 We fully acknowledge that the electronic prescribing system has not been introduced 
into the critical care areas in South Tees. This is related to the requirement for a 
major refurbishment project in CICU which is likely to be completed in early 2026. 

You were concerned that the Trust’s record keeping and prescribing systems were 
fragmented and lacked integration. We would like to respond to your concerns in full. 

The Trust commenced the gradual implementation and roll out of the “Better 
Medications” electronic prescribing and medicines administration (ePMA) system in 
July 2022. The Cardiology department commenced integration in March, and this 
was completed in April 2023.  This is hosted inside a software portal provided by 
Alcidion called Miya Precision.  This is a solution which digitises the process of 
prescribing and recording medication administered to inpatients within the Trust. 

The benefits of introducing an ePMA system are widely recognised to improve 
patient safety through a reduction in medication errors. Within this Trust we have 
found that improvements have been made in the following areas:  

•  There has been a 17% reduction in prescribing errors in comparison with 

previous audits relating to incorrect time/frequency/route 

•  Antimicrobial stewardship audits have shown improvement: indication of 

treatment has improved from 82% to 94%, review date 76% to 100%, 100% 
compliance allergy status 
Improvement in prescribing in line with clinical guidelines due to drug order 
sets customised build within the ePMA 

• 

•  Rapid tranquilisation audit demonstrated a 50% improvement with the use of 

• 

ePMA 
Insulin prescribing compliance has increased from 25% compliance with 
guidance to 100% compliant 

Additional benefits to medication safety are as follows: 

•  Medication records are stored electronically and are available 24/7 and can 

be accessed remotely  

•  Patient’s medication history, decision support and online resources available 

to aid prescribing, with allergies and interactions highlighted 

•  The system will give extensive and robust audit information on medicines 

usage. 

•  A live electronic medication safety dashboard has been developed for omitted 

doses, VTE prescribing and critical medicines.  

•  Lab results are now integrated into Miya and is visible in the drug chart 
•  Clinical decision support now in place 
•  Customised warnings, hard stops and maximum prescribing doses are now in 

place  

In addition to ePMA, improvements have been apparent in other patient safety 
mechanisms which are in place in relation to medication: 

 
 
 •  There has been an increase in investment in the clinical pharmacy service- 

with an increase in the number of technicians in the Cardiology department by 
two whole time equivalents.  This has released pharmacists’ capacity for 
medication reviews and has improved the medicines reconciliation rates that 
are completed within 24 hours of admission.  

•  GPICS (Guidelines for the Provision of Intensive Care Services) is the 

definitive reference source for planning and delivery of UK Intensive Care 
Services. The Trust is now compliant in the critical care for clinical pharmacy 
element of GPICS and has the required step-down procedure in place 
•  The Trust has introduced new and innovative roles to release capacity for 
clinical teams; this includes a ward medicines assistant in Cardiology 

•  At the time of Mr Cogdon’s admission (June 2023) 1% of patients were seen 
by the clinical pharmacy cardiothoracic team within 24 hours of admission.  
The rate has now increased to 45% and it is a priority within the next phase of 
the medicines reconciliation business case to expand the 7-day service 

•  On review of current ePMA training compliance, 95% of cardiology 

anaesthetists had completed ePMA online training and had access to the 
system to view/prescribe medications. 

We would like to address the concerns raised by the witness that there is no linkage 
between the ward and ITU systems.  We also note the findings of the Mortality 
review: (the fact that MIYA was only available on some wards is an issue – 
transcription errors between MIYA and drug charts noted… Omission of 
Lansoprazole a factor in his death because of the Gastrointestinal Bleed (GI) but it 
was the HIT that compromised his medical management).  

In order to address these concerns, we will initially outline Mr Cogdon’s journey 
through the hospital departments describing which medications were prescribed and 
on which system, how they were transcribed and subsequently administered, and at 
which points there were errors and omissions within this process.  

On review of Better Medications electronic drug chart (Miya), Mr Cogdon’s initial 
dose of Lansoprazole was prescribed 30mg once daily for 1 day only on 20/6/23 until 
21/6/23. Mr Cogdon had been taking this daily prior to admission alongside 
Clopidogrel 75mg once daily and Aspirin 75mg once daily. Lansoprazole, or an 
equivalent proton pump inhibitor (PPI), should have continued throughout his stay. 
This was a prescribing error which was not linked to ePMA.  

Mr Cogdon was transferred to theatre on 26/6/23.  The usual process is for an 
anaesthetist to review the drug chart and prescribe post-operative medications. 
Patients who are transferred to the cardiothoracic intensive care unit post operatively 
would usually have PPI prescribed throughout their stay and reviewed daily on the 
consultant-led morning ward round. However, no PPI was prescribed for Mr Cogdon 
during the post-operative period although Lansoprazole is noted on the anaesthetic 
chart in the list of regular medications.  This was a prescribing omission unrelated to 
ePMA. 

 
 
 
 
 On 30/6/23 regular PPI IV Omeprazole was prescribed to Mr Cogdon but was 
intentionally not given and was replaced with Pantoprazole 40mg twice daily in line 
with the Trust’s GI bleeding protocol.  This was commenced on 1/7/23 for 72 hours 
due to duodenal bleeding with subsequent Lansoprazole 30mg prescribed twice 
daily until 11/7/23. On readmission to cardiothoracic intensive care unit there was a 
reduction in Mr Cogdon’s dose of Lansoprazole to 30mg once daily.  It is not clear 
whether this was a deliberate reduction given that Mr Cogdon had received 10 days 
of high dose treatment or whether this was a transcription error. The opinion of a 
senior Gastroenterologist was that 10 days of high dose treatment was acceptable 
practice. 

On 25/7/23 Lansoprazole was switched to Pantoprazole 40mg twice daily, this dose 
was then reduced to once daily on 26/7/23 and increased back to twice daily on 
28/7/23. Lansoprazole 30mg twice daily was then recommenced on 31/7/23. 

We would like to thank you for highlighting these matters of concern, and for giving 
us the opportunity to respond.  It is the Trust’s position that we have taken the 
relevant steps to integrate the hospital systems used in the safe and effective 
prescribing of medication since Mr Cogdon’s admission. We hope this additional 
information provides you with assurance that any concerns you had during the 
Inquest have been addressed by the organisation. We are more than happy to 
discuss further if this would be helpful. 

We would like to thank you for highlighting this matter of concern, and for giving us 
the opportunity to respond.  We hope this response provides you with assurance that 
your concerns have been addressed by the organisation. On behalf of the Trust, we 
would once again like to express our sincerest condolences to Mr Cogdon’s family.   

Yours sincerely 

Group Chief Medical Officer 

University Hospitals Tees    

Site Medical Director 

South Tees Hospitals