Summary
On 18 December 2022, Emily Harkleroad collapsed when out with a friend. She was taken by ambulance to the University Hospital of North Durham Emergency Department. Despite staff recognising that pulmonary embolism was the likely diagnosis, there were failures to provide Emily with appropriate and timely treatment for pulmonary embolism. Errors and delays in the Emily’s medical treatment resulted in her not receiving the anticoagulant treatment that she needed, and which would, on a balance of probabilities, have prevented her death. She died as a result of pulmonary embolism in the early hours of 19 December 2022 at the University Hospital of North Durham.
Content
Coroner's MATTERS OF CONCERN are as follows:
The Coroner heard evidence that in or around October 2022 a new computer system was introduced into the Emergency Department of the University Hospital of North Durham. The provider of the new system is Cerner. Cerner is now owned by Oracle Corporation.
The Coroner heard evidence that the previous software in use in the Emergency Department included a “RAG rating” system, which ensured that the acuity of the patients was easily identifiable by looking at a single page on a display screen. The Coroner heard evidence that the new Cerner software did not include such a system. Instead, the Cerner software has symbols next to patient’s names that, when clicked on, provide an indication of the level of acuity of the patient, but not a clear indication at first glance.
In summary, the Coroner was told that the previous RAG rating system was an effective tool in quickly identifying patients requiring urgent oversight by senior clinicians, especially when the Department was under extreme pressure. It is the Coroner's 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. The Coroner was told that concerns about the absence of a RAG rating type system had been raised by a number of clinicians, but that the response, thus far, had been that the new system does not have that functionality.
0 Comments
Recommended Comments
There are no comments to display.
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now