Newly installed EPR contributed to A&E death, warns coroner

A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned.

Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said.

The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients.

The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system.

The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity.

Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”.

“It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.”

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Source: HSJ, 23 February 2024