“(brief summary of matters of concern) Gillian Peacock was admitted to hospital on 27th…”
Dated 5 Jun 2024, from the coroner for County Durham and Darlington. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 31 Jul 2024. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated5 Jun 2024
- Deadline31 Jul 2024
- Published on judiciary.uk14 Jun 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| County Durham and Darlington NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
(brief summary of matters of concern) Gillian Peacock was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithomycin. It was recorded by a hospital pharmacist on 1st March 2023 in her medical notes that the use of these two drugs can cause digoxin toxicity and an alternative drug or monitoring is advised. No alternative drug was prescribed and no monitoring took place until 7th March 2023. The evidence I have heard is that the treating clinicians had not seen the entry in her medical records. This was in part due to the way the entries are displayed in the records and the 'huge' number of entries that are recorded. I heard that now that any pharmacist entries of significance must 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. 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 use of verbal handovers does not in my view fully address my concern that 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. In addition, that it can be accessed immediately without reliance on the verbal passing of information from one member of the treating team to another.
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, 2024-0313
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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