Coroner's warning after medics missed vital advice

An inquest was held into the death of Gillian Peacock, who died after being treated at Darlington Memorial Hospital

Doctors missed warnings on a patient's medical record and gave her a life-threatening mix of medication days before she died, a coroner said.

Gillian Peacock was prescribed clarithromycin for a chest infection at the same time as taking digoxin for her heart condition, sparking concerns from a Darlington Memorial Hospital pharmacist that were not acted upon.

There could be risk of future fatalities if action is not taken by the hospital trust, a Prevention of Future Deaths report said.

A spokeswoman for the County Durham and Darlington NHS Foundation Trust said a thorough investigation had been carried out.

Offering condolences to Mrs Peacock's family, she added: "We are preparing a detailed response for the coroner and to identify any opportunities for learning."

The 60-year-old, from Bishop Auckland, died after a cardiac arrest in March 2023, but a post-mortem examination could not identify a cause of death.

An inquest was held and James Thompson, assistant coroner for County Durham and Darlington, subsequently issued a Prevention of Future Deaths Report outlining the action the trust should take in the wake of Mrs Peacock's death.

Pharmacist advice

It said Mrs Peacock, who had several health conditions, was admitted to the hospital on 27 February and diagnosed with a chest infection.

After she was prescribed clarithromycin to treat it, a hospital pharmacist wrote in her medical notes that the use of the drug when combined with the digoxin can cause digoxin toxicity.

The pharmacist recommended using an alternative drug or monitoring Mrs Peacock.

The report said treating clinicians did not see that entry in the medical notes, because of the way entries are displayed and because of a "huge" number of entries recorded.

No alternative drug was prescribed and no monitoring was carried out until 7 March, when results showed elevated levels of digoxin in her system. That medication was subsequently stopped.

She showed no recognised symptoms of digoxin toxicity during her hospital stay.

Mrs Peacock died after suffering a cardiac arrest on 8 March, the report said.

"The medical evidence cannot on the balance of probabilities determine the contribution of digoxin and clarithromycin to her death," it added.

Matters of concern

The Prevention of Deaths Report highlights Mr Thompson's concern about record keeping at the hospital.

He said: "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 report said significant pharmacist entries must now 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.

But Mr Thompson said the verbal handovers do not fully address his concern.

"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," he added.

He said the information should be able to be accessed immediately without reliance on the verbal passing of information from one member of the team to another.

The trust's response to the coroner's concerns must be submitted before the end of July, and should outline action taken or planned in response to the concerns raised.