Hospital IT system warning after 'preventable' death

Emily Harkleroad, 31, died from a blood clot in 2022

A coroner has issued a warning over a hospital’s new computer system after the death of a 31-year-old woman.

Emily Harkleroad collapsed on 18 December 2022 and was taken to the University Hospital of North Durham, where she died the next morning from a pulmonary embolism – a clot on the lung.

The assistant coroner for County Durham and Darlington concluded, on balance, that Ms Harkleroad’s death could have been prevented. She also noted computer system concerns had been raised by a number of clinicians.

County Durham and Darlington NHS Foundation Trust (CDDFT) said it took the coroner’s report extremely seriously.

An inquest was opened on 6 January 2023 into the death of Ms Harkleroad, who had previously worked at the trust as a dietitian, and it concluded on 17 January 2024.

Despite staff recognising that pulmonary embolism was the likely diagnosis, the inquest heard "errors and delays" in her medical treatment resulted in her not receiving the anticoagulant – or blood thinning treatment - that she needed quickly enough.

The hospital trust started to use the new IT system in October 2022, two months before Ms Harkleroad's death

Assistant coroner Rebecca Sutton said she had "serious concerns" about a new computer system introduced in the hospital's emergency department, and believed there was a risk that future deaths could occur, unless action was taken.

She said the previous system in the emergency department included a red, amber and green alert system or RAG, which quickly identified to doctors which patients needed urgent care.

But Ms Sutton said the new Cerner computer software did not have this alert system.

Instead, the software had symbols next to patients' names that clinicians had to click to see how urgently they needed care, meaning there was no clear indication at first glance.

Prevent future deaths

The trust started to use the new IT system in October 2022, two months before Ms Harkleroad's death.

Ms Sutton said the previous RAG rating system was "particularly effective" in times of extreme pressure in the emergency department, as a quick and clear way of identifying the most critically ill patients.

She also said it was an important tool that could prevent future deaths.

The coroner added concerns about the new IT system had been raised by a number of clinicians but the response, thus far, had been it does not have that functionality.

The coroner has written to the hospital trust demanding action, giving it 56 days to explain what steps are being taking.

A spokesperson for County Durham and Darlington NHS Foundation Trust said: "We send our sincerest condolences to Emily’s family and take the findings of this report extremely seriously.

"We will be responding to the coroner within the required timescales and it would be inappropriate to comment further whilst that process is ongoing."

Oracle Corporation purchased Cerner Corporation in December 2021.

The BBC has contacted Oracle for comment.