Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0630, written 17 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2025 |
|---|---|
| Reference | 2025-0630 |
| Deceased | Valerie Gibson |
| Coroner | David Place |
| Coroner area | Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
David Place Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive of Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust 1 CORONER I am David Place, His Majesty’s Senior Coroner for the City of Sunderland 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 29th October 2023 I commenced an Investigation into the death of Ms Valerie Jane Gibson, who died in Monkwearmouth Hospital, Sunderland on 29th October 2023 aged 64 years. The Investigation concluded at the end of the Inquest on 5th December 2025. The medical cause of death was confirmed as: - Ia The cardiac effects of olanzapine and left ventricular diastolic dysfunction II Liver fibrosis and the effects of morphine, diazepam and temazepam The Jury recorded a narrative conclusion ‘Natural causes contributed by the use of olanzapine to treat psychosis.’ 4 CIRCUMSTANCES OF THE DEATH Valerie died on 29th October 2023 at Monkwearmouth Hospital. She had been admitted to the hospital on 21st October 2023 under s2 Mental Health Act 1983. She was suffering from delusional thoughts, hallucinations and persistent thoughts in keeping with psychosis and possible depressive illness. She was assessed to be at risk of self-harm and a risk to others. The working diagnosis was paranoid schizophrenia. Although her property was checked upon admission, she received more possessions the day after her admission, and these were not checked and were given to her. These included a coat which contained one type of her prescribed medication. She had not been compliant with taking prescribed medication to treat psychosis prior to her admission so this was restarted at a low dose of which increased on 27th October 2023. Between dates of 27th October 2023 - 29th October 2023 there was uncertainty whether she had received her prescribed or non-prescribed medication. She was found unresponsive at 08:26am on 29th October 2023 having been observed to be snoring at 07:45am. HM Coroner’s Courts, City Hall, Plater Way, Sunderland SR1 3AA Tel 0191 5617843 email: coroner@sunderland.gov.uk | web: www.sunderlandcoroner.co.uk 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are: – Valerie was an extremely vulnerable woman who had suffered with mental health concerns for a number of years. She was admitted to Monkwearmouth Hospital on 21st October 2023 under s2 Mental Health Act 1983. The matters of concern are not found to be causative of Valerie’s death but are such that there is a risk that future deaths may occur unless action is taken. I was concerned that the evidence highlighted significant staff uncertainty and confusion as to the correct process for dispensing and administering of medication resulting in complete lack of clarity as to what medication had been dispensed and what had been administered to patients which could easily lead to patients being over or under medicated. It became clear in evidence that there was not a thorough check of Valerie’s possessions which arrived after she had been admitted. All possessions, no matter when they arrived, should have been checked. Additional tablets were found in a coat pocket and that coat was one of the possessions that arrived the day after her admission and was given to her without being checked. On balance of probabilities, toxicology suggested that Valerie had not consumed additional tablets over and above her prescribed dose, but there was clearly the opportunity for her to do so with staff admitting they would not have known if she had. The evidence highlighted a lack of understanding with regard to supervision requirements for preceptee nurses resulting in medication being administered without supervision and being recorded on a patient’s electronic medication record (ePMA) as being administered by a different registered nurse. There was no consistency in the evidence from the nursing staff as to the correct use of the Omnicell medication cabinet and the electronic medication record (ePMA). This resulted in different approaches being taken leading to differences between medication recorded as being dispensed from the Omnicell cabinet and that being recorded as administered to the patient on the electronic medication record (ePMA). Between 27th and 29th October 2023 Valerie’s Omnicell record showed that liquid medication had been dispensed for her. She was not prescribed this medication. Her electronic medication record (ePMA) showed that tablet medication was administered to her which was her prescribed medication. Each nurse had a different understanding as to what the correct procedure was to dispose of liquid medication incorrectly dispensed. One thought it went straight into the blue disposal bin but the other did not think that was the case. The group medical director also had a slightly different view that a liquid could be disposed of in the blue disposal bin if it was in a sealed container. This added to the confusion over which medication had been administered to Valerie. It was apparent that the Omnicell and electronic medication record (ePMA) are two distinct and separate systems that are supposed to be used alongside each other but the evidence highlighted the potential flaws in that approach due to the reliance on the person using the system adopting the correct approach. I was shocked that the Omnicell did not refer to a patient’s prescribed medication and relies on the nurse dispensing to have correctly identified from the patient’s electronic record (ePMA) the correct prescription and then inputting the correct medication and dose to the Omnicell. Differing amounts were inputted and on 28th October 2023 and stock levels of the non-prescribed liquid medication showed a significantly large reduction which was over 3 times a normal dose with Page 2 of 3 no evidence a spillage had occurred and no incident report completed. In addition, small doses were inputted to enable the medication to be returned to the cabinet if the door had shut before the nurse had replaced the bottle. This led to complete confusion over stock levels, what had been dispensed and whether it had been disposed of or administered to the patient. The evidence confirmed that on occasions the patient’s electronic medication record (ePMA) showed that medication had been administered to the patient before it had even been dispensed from the Omnicell cabinet with nurses admitting this was likely done to reduce workload during a busy medication round. This resulted in Valerie being recorded as receiving all of her medication on the morning of 29th October 2023 which was not the case as she was sadly found unresponsive before any medication was given to her and subsequently passed away. The evidence suggested there were alternative ways to access controlled drugs within the Omnicell cabinet without the use of a 2nd fingerprint signature by using a stock code normally used by pharmacy when restocking the cabinet adding to the confusion over what was dispensed and what was administered. I shall be glad to be told of any learning arising from this death and timescales and results of your review. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 11th February 2026. 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: - • Family and their Solicitors • Nurse L and her Solicitors • Care Quality Commission I am also under a duty to send the Chief Coroner and all interested persons, who in my opinion should receive it, a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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 this 17th day of December 2025 Signature: HM Senior Coroner for the City of Sunderland Page 3 of 3
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.
Mr David Place HM Senior Coroner for the City of Sunderland City Hall Plater Way Sunderland SR1 3AA Safer Care St Nicholas Hospital Jubilee Road Gosforth Tyne and Wear NE3 3XT 10th February 2026 Dear Mr Place Inquest into the death of Valerie Jane Gibson Response to Regulation 28 Report; Prevent Future Deaths Response This response has been prepared by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (“The Trust”) and addresses the concerns as set out by HM Senior Coroner in his Regulation 28 Report dated 17 December 2025 following the investigation into the death of Valerie Gibson. Digital medicines technologies such as electronic prescribing (EPMA) and automated dispensing (Omnicell) are supportive tools which evidence shows reduce medication errors and costs while improving productivity. However, they remain reliant upon clinicians’ due diligence and professionalism when interacting with these tools, underpinned by appropriate education, training and robust governance arrangements. Based on the evidence heard at inquest and the concerns of HM Coroner; the Trust has stood up an executive led Incident Management Review Group comprising of senior operational staff, pharmacy leads, service leads, training leads and patient safety specialists. It has focused on the human / system interface, professional culture, and training and competency assessment in medicines administration to address the concerns. The Trust will respond to each of the Coroner’s concerns in turn. 1. Evidence highlighted significant staff uncertainty and confusion as to the correct process for dispensing and administering of medication resulting in complete lack of clarity as to what medication had been dispensed and what had been administered to patients which could easily lead to patients being over or under medicated. Trust Response The Trust has already taken several actions in relation to this concern, with additional actions underway. These actions are in some cases applicable across several of the Coroner’s concerns. - An alert on the Trusts Access Request Management System (ARMS) has been established to alert ward-based pharmacy teams whenever a new member of Trust nursing staff commences employment so that face to face Omnicell training can be delivered during their induction period. - Ward based pharmacy teams have received updated face to face Omnicell training, this updated training has also been offered to nursing teams across bed based services. - Omnicell guides and training checklists have been updated and are available to all staff on the Trust intranet and have been circulated via the Trust bulletin. - Nursing staff medicines competencies have been reviewed and updated to include use of EPMA and Omnicell. - The Trust Medicines Optimisation Policy and medicines management e- learning package have also received updates related to Omnicell task competencies and use of EPMA, policy updates have been circulated to staff via the Trust policy bulletin. - The Trust has adopted the ‘6 Rights of Medicines Administration’ (6R’s), a NICE-recommended safety framework designed to reduce the risk of medication errors during the administration process in health and care settings. The 6R’s are, Right Patient, Right Medicine, Right Dose, Right Route, Right Time, Right Documentation. The Framework is to be rolled out across CNTW, posters have been prepared for circulation and are awaiting approval of the Medicines Optimisation Committee (MOC) on 11/2/26. With Trust wide communications via the Bulletin and pharmacy Internet page to follow thereafter. - In addition to the above, a Task and Finish group has been established to develop further actions and initiatives related to safer practice in medicines administration. The group met initially on 22/1/2026 and are scoping: • Mandatory Omnicell training and assessment for nurses with centralised record keeping; • Further review of medicines competency assessment to make it more practice based, providing enhanced support and guidance for the assessment and competency of nursing staff. This will also cover how to support staff who do not meet the required competency level. • Current barriers for safe medicine administration practice and possible solutions e.g. Ward Medicine Assistants, medicine management / digital nurse leads. 2. There was not a thorough check of Valerie’s possessions which arrived after she had been admitted. Additional tablets were found in a coat pocket and 2 that coat was one of the possessions that arrived the day after her admission and was given to her without being checked. Trust Response The Trust has a policy CNTW(C)11, complimented by local operational procedures held at ward level, these are being reviewed and updated with the learning from this case. In relation to this concern, the current process around the checking of property is to be reinforced to ensure that all clothing pockets are checked as part of a property search. This will be made explicit in the search policy and associated training. 3. Evidence highlighted a lack of understanding about supervision requirements for preceptee nurses resulting in medication being administered without supervision and being recorded on a patient’s electronic medication record (ePMA) as being administered by a different registered nurse. Trust Response In line with national guidance the Trust policy remains that the nurse who dispenses the medication must administer it to the patient and record the administration on ePMA. If a medicines round is being completed with a preceptee or student, they should be supervised / accompanied throughout the entire process. In response to the learning highlighted in this case, a scenario of a medicines round being conducted as part of a student or preceptees training will be included in scenario based training as part of the review of the medicine’s competency assessment for qualified nursing staff. 4. There was no consistency in the evidence from the nursing staff as to the correct use of the Omnicell medication cabinet and the electronic medication record (ePMA). Between 27th and 29th October 2023 Valerie’s Omnicell record showed that liquid oral morphine solution had been selected for her. However, she was not prescribed this medication. Her electronic medication record (ePMA) showed that morphine modified-released capsules were administered to her, which was her prescribed medication. Trust Response In addition to actions outlined under concern 1, the following has occurred: A) The pharmacy team has led a Trustwide switch from morphine sulphate oral solution 10mg/5ml (Oramorph) to morphine sulphate oro-dispersible tablets (Actimorph), as the preferred 1st line product. This will reduce the issues highlighted in this case regarding the use of liquid Controlled Drugs (CD’s). B) Further guidance on the reporting of CD discrepancies has been added to the Trust Medicines optimisation policy. The Nurse Medicines competency assessment has had additional content added regarding medicines formulations (immediate release vs modified release). From a governance and assurance perspective the following is underway: 3 A) A CD stock adjustment report to highlight unusual Omnicell stock balance adjustments is in development, and an escalation process has been agreed with bed-based services. B) Operational Nurse Directors are responsible for ensuring ward based staff are aware of the need to report any CD discrepancies. C) Aligned with this, the Controlled Drugs Accountable Officer delivered a controlled drugs briefing to operational nurse managers in January 2026. The Trust are also working with its electronic care records system supplier to explore the possibility of an automated reporting of stock balance adjustment report from the Omnicell system. 5. Each nurse had a different understanding as to what the correct procedure was to dispose of liquid medication incorrectly dispensed. Trust Response The Trust have in place a medicines optimisation policy and an e-learning module that covers the procedure for disposal of liquid medications. However, considering the learning highlighted by this case, we have taken the decision to review and amend the nurse medicines competency assessment, which will include liquid medicines disposal. All qualified nursing staff complete the competency assessment every 3 years. A Task and Finish group has commenced this piece of work and is being supported by pharmacy input, as described in 1 above. 6. The Omnicell and electronic prescribing and medicines administration system (ePMA) are two distinct digital systems that operate alongside each other, with patient demographic details shared between them. Omnicell reduces the risk of drug selection errors by guiding the nurse to the correct location within the cabinet for the prescribed medicine. However, the evidence highlighted that this approach still requires the nurse to select the correct medicine from the stock held within it and does not reduce the risk of selection errors to zero. Trust Response Potential integration of the two systems (a ‘closed loop system’) has been considered in conjunction with NHS England and Omnicell. At the present time integration of Omnicell and EPMA is not a viable option. There is limited published evidence from the acute sector of successful integration and no examples of integration within a Mental Health Trust. The process of integration would involve significant financial investment as well as the introduction of patient allocated barcodes / wristbands, which may bring unintended patient safety risks and would require careful consideration and consultation with stakeholders. The Trust will continue to work with the system suppliers to improve connectivity and innovation to enhance patient safety and workflow. 4 7. The evidence confirmed that on occasion the patient’s electronic medication record (ePMA) showed that medication had been administered to the patient before it had been dispensed from the Omnicell cabinet, with nurses admitting this was likely done to reduce workload during a busy medication round. Trust Response In relation to this finding the Trust has added a segment to its medication administration e-learning package around ‘the Rights of Medication Administration’. A poster for display in clinics / dispensing areas has also been produced to raise awareness. In addition, the review of the medicine’s competency assessment will include a section on the correct sequencing involved in medicines administration. The Trust Pharmacy service is also in the process of developing educational / instructional videos to support the use of Omnicell. 8. The evidence appeared to suggest there was an alternative way to access controlled drugs within the Omnicell cabinet without the use of a 2nd fingerprint signature, by using a stock code normally used by pharmacy staff when restocking the cabinet. Trust Response Further investigation of this concern has occurred since the inquest, and while an incorrect restock code (as opposed to a medicines issue code) was used to open the patient’s own medicines drawer, this did not allow access to the controlled drug compartments (bins) within the drawer. The controlled drug compartments (bins)require two fingerprints to open. Therefore, controlled drugs remained accessible only through the use of a ‘witness’ fingerprint from a 2nd nurse. We hope that the information provided offers the necessary assurances that the Trust has acted in light of the concerns raised and continues to look to improve and strengthen its systems, processes and staff competency. We would also like to extend again our sincere condolences to the family of Valerie. Yours sincerely Executive Director of Nursing and Therapies 5
See every Prevention of Future Deaths report matching Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.