“During the course of the inquest it was established Mrs Lydon was diagnosed with a…”

The coroner’s concerns

(1) During the course of the inquest it was established Mrs Lydon was diagnosed with a condition and treatment was prescribed in the form of a repeat prescription drug in May 2021. The diagnosing consultant set out the treatment plan in a letter to her GP and the format of the letter was such it was difficult for the receiving GP to see what actions were required by him. This is compounded when paper correspondence is routinely scanned and emailed by administrators and the GP is 'drawn' to certain sections of the document by the administrators. It was remarked in evidence by the GP that all consultants seem to format their correspondence differently and there is no uniform format so a GP can see clearly at the outset what the treatment plan is and what action needs to be taken. Evidence from the Hospital Trust in question stated they had changed the format of this type of correspondence to make it easier to identify the actions to be taken. In Mrs Lydon's case, the drug she was prescribed in May 2021 was not identified from the correspondence and was supplied to her in June 2022 when the situation was discovered. Whilst a remedy has been implemented locally I have a concern that nationally there is a risk of future deaths if important correspondence contained treatment plans is not clearly communicated to those responsible for implementing them. (2) Evidence was given at inquest that when a diagnosis is made by a specialist in a secondary care setting, if drugs are to be prescribed that must be undertaken by the patient's GP. It was confirmed that the current practice does not allow for a specialist to issue a prescription for the required drugs at the point of diagnosis and then instruct the patient's GP to continue the process. In Mrs Lydon's case this would have ensured she received the clinically indicated drugs immediately. (3) On Mrs Lydon's admission to hospital in Gateshead in July 2022 certain investigations, treatments and diagnosis were made. She was then discharged and returned to hospital in South Tyneside, a neighbouring NHS Trust in August for what amounted to a further 3 hospital admissions there before her death. Evidence was heard that the doctors in South Tyneside whilst aware of her recent admission in Gateshead could not access her medical records for that admission. They requested them in August, but they were not supplied until November, after she had died. I understand much work regionally has been undertaken since 2022 with North East England based NHS Trusts to make 'real time' access to patient records possible, but whilst improved it is not complete and this is also a national issue I understand. Given the two hospitals Mrs Lydon was a patient in are only 6 miles apart it raises a concern that doctors attending Mrs Lydon in one location are denied access to another hospital records so close at hand and I understand this is not a position unique to these hospitals. To me, the inability of doctors to promptly access a patient's medical records from other NHS Trusts to provide the best possible care creates a risk of future deaths.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0244

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0