14 Oct 2025 Paula Doreen Hughes · Prevention of Future Deaths report Inner South London
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Concerns raised 7 Failure to prevent concurrent prescriptions of paracetamol-containing drugs View source Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity View source Lack of a mechanism for consistently recording pre-admission over-the-counter medications View source Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element View source Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews View source Lack of a robust process for managing therapeutic excess and potential toxicity View source Risk of loss or dilution of prescribing safety nets during electronic system changes View source See 4 more concerns
Responses linked to these concerns
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AI-generated summary
Paula Doreen Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent concurrent prescriptions of paracetamol-containing drugs
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity
Wider context from the report “5. Trust approach to mitigating against confirmation bias and encouraging professional curiosity (LGT)
Confirmation bias and a lack of professional curiosity were significant features in Mrs Hughes’ being administered two paracetamol containing drugs at the same time and in not investigating whether she had received a therapeutic excess and suffered consequential harm. I have found that the Trust does not have robust mechanism for mitigating against confirmation bias and encouraging professional curiosity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for consistently recording pre-admission over-the-counter medications
Wider context from the report “4. Mechanism for recording over the counter medications taken prior to attendance at the Emergency Department (LGT)
This concern has arisen out of my finding that Mrs Hughes had taken an over the counter (OTC) drug containing paracetamol before her admission to hospital but that this had not been recorded as part of her medication history. The Trust’s Medicines Reconciliation Policy requires that patients should be asked about OTCs. The Trust relies on individual clinical practice. There is no mechanism to ensure that pre-admission OTCs are consistently recorded such that the risk of therapeutic excess of paracetamol (or other drugs available OTC) in those circumstances continues to exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element
Wider context from the report “3. The assessment of the ACVPU score (LGT, RCP, NHSE)
This concern has arisen out of the fact that Mrs Hughes was scored as alert when she was confused. Confusion would have added a score of 3 to her NEWS2 score and would have resulted in an earlier escalation of her condition. I heard that confusion is not always easy to identify and that the signs can be subtle.
(1) LGT
The Trust provided training materials relating to detection and management of deteriorating patients. There was minimal guidance on how to accurately assess the ACVPU score and the confusion element in particular. There remains a tangible risk that the ACVPU score will continue to be assessed inconsistently, with new episodes of confusion continuing to be missed.
(2) NHSE, RCP
I consider that consistent and accurate assessment of the ACVPU element of the NEWS2 score is likely to a matter of wider concern. This concern is being brought to the attention of NHSE and the RCP as I consider that they have the power to support healthcare professionals to ensure consistent and accurate scoring of confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews
Wider context from the report “6. Trust policy on managing virtual patient reviews (LGT)
This concern has arisen out of the fact that Mrs Hughes had been reviewed virtually rather than face to face a resident doctor on the morning before she became unwell. The Trust has no guidance or policy on virtual reviews. I was told that this is a matter of clinical judgment. The absence of any guidance to help a still relatively inexperienced resident doctor decide when they can dispense with a face-to-face review is a circumstance that creates a risk that future deaths may occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust process for managing therapeutic excess and potential toxicity
Wider context from the report “2. Management of therapeutic excess if it has not been prevented (LGT)
This issue has arisen from the finding that once the concurrent prescription had been identified, there had no attempt to consider whether there had been a therapeutic excess and whether Mrs Hughes had suffered harm. The Trust’s response to the incident focused on prevention. It did not consider the adequacy of the clinical response once the overdose had been identified. The Trust relies on information sharing of learning from incidents and thereafter places reliance on individual clinical practice. I received no evidence of a robust process for ensuring a consistent clinical response to the management of therapeutic excess and the potential for toxicity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Risk of loss or dilution of prescribing safety nets during electronic system changes
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing and monitoring Trust-client awareness of duplicate-prescription and paracetamol overdose alert functionality.
Verbatim wording from the response “15. Oracle Health considers that the Millennium prescribing system features are appropriate and functioning as designed in respect of the risk of duplicate paracetamol doses, including the Prescription Duplicate Alert Notification and the Administration Alert Notifications. Oracle Health will continue to review and monitor awareness of this functionality among its Trust clients.” Source location Response from Oracle
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue discussing potential software or configuration enhancements with clients, including their appropriateness and workflow impact.
Verbatim wording from the response “14. As noted above, Oracle Health continuously engages in ongoing dialogue with its clients regarding software code and configuration enhancements to its Millennium solutions. Such enhancements can arise at the global, or national, level in response to the knowledge and experience gained by Oracle Health from working with its extensive client base. They can also arise in response to specific issues at the level of local deployments. In each case, Oracle Health will discuss with its client the appropriateness of taking a potential upgrade and its impact on existing workflows and the user interface. Ultimately, the decision on whether to take a particular code or configuration enhancement remains with the client and can involve clinical and commercial considerations.” Source location Response from Oracle
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with Trust clients to inform and educate them about available alert functionality.
Verbatim wording from the response “2.5. Oracle Health does not consider that any further code development of alert notifications is required, but it continues to augment the content and function of all alert notifications and Millennium in general. Oracle Health will continue to work closely with its Trust clients to inform and educate them on the available functionality.” Source location Response from Oracle
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss safeguards against paracetamol dosing incidents with Trust clients through quarterly meetings.
Verbatim wording from the response “2.4. Oracle Health has no record of LGT raising any relevant service or test issues as part of the deployment testing process or subsequent to the systems going live. Approaches to safeguard against paracetamol dosing incidents were discussed with a number of Trust clients, including LGT, at a regular quarterly meeting in June 2024.” Source location Response from Oracle
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the UK Administration Alert Notification and explain its triggers, operation and implementation options to Trusts through a Special Interest Group meeting.
Verbatim wording from the response “13. Oracle Health holds Special Interest Group (“SIG”) meetings approximately every quarter, which enable Oracle to share enhancements, upgrades, and best practices with regard to Millennium functionality. They also enable clients to come together and present on any issues encountered within particular fields. At a SIG meeting in September 2022, Oracle Health introduced the Administration Alert Notification in the UK, including details about its form, how the alert is triggered, and how Trusts could seek to implement it. Trust clients in attendance also provided feedback on how the alert notification might be refined in the future. At a SIG meeting in June 2024, LGT raised in general terms paracetamol dosing incidents as a topic for discussion among other Trust clients, including whether any additional alert notifications may have been implemented by those Trusts internally.” Source location Response from Oracle
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present updates to the Administration Alert Notification, including patient-weight-based maximum-dose calculations, to Trust clients.
Verbatim wording from the response “At the same meeting, Oracle Health presented updates to the Administration Alert Notification, including functionality that would take into account the patient’s weight in calculating the maximum dose before triggering the alert notification.” Source location Response from Oracle
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue augmenting the content and functionality of Millennium alert notifications, including overdose-related alerts.
Verbatim wording from the response “2.5. Oracle Health does not consider that any further code development of alert notifications is required, but it continues to augment the content and function of all alert notifications and Millennium in general. Oracle Health will continue to work closely with its Trust clients to inform and educate them on the available functionality.” Source location Response from Oracle
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a detailed review of Millennium’s duplicate-prescription and paracetamol overdose alert functionality.
Verbatim wording from the response “2. Oracle Health was saddened to learn of, and deeply regrets, the various medical omissions at the Queen Elizabeth Hospital (“QE Hospital”) and extends its condolences to the family of the Deceased and others bereaved. Oracle Health assures the Deceased’s family that the contents of the Report are taken extremely seriously. While there is no suggestion that Oracle Health’s Millennium software deployed at the QE Hospital was in any way at fault or contributed to the Deceased’s death, Oracle Health conducted a detailed review of that software in response to the Report and concludes as follows (key findings are highlighted in bold throughout):” Source location Response from Oracle
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No evidence has been identified that the software contains a defect or deficiency relevant to duplicate paracetamol prescribing.
Verbatim wording from the response “2.1. Oracle Health was invited to comment on one specific issue in the Report, out of a number of identified issues, which issue related to concurrent prescriptions of paracetamol and duplicate checking functionality. Further to its review, Oracle Health has not identified any evidence of any defect or deficiency in its software.” Source location Response from Oracle
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing prescribing and administration alert functionality is considered appropriate and functioning as designed, so further alert-notification code development is unnecessary.
Verbatim wording from the response “2.5. Oracle Health does not consider that any further code development of alert notifications is required, but it continues to augment the content and function of all alert notifications and Millennium in general. Oracle Health will continue to work closely with its Trust clients to inform and educate them on the available functionality.” Source location Response from Oracle
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The client decides whether to adopt particular code or configuration enhancements, taking account of clinical and commercial considerations.
Verbatim wording from the response “14. As noted above, Oracle Health continuously engages in ongoing dialogue with its clients regarding software code and configuration enhancements to its Millennium solutions. Such enhancements can arise at the global, or national, level in response to the knowledge and experience gained by Oracle Health from working with its extensive client base. They can also arise in response to specific issues at the level of local deployments. In each case, Oracle Health will discuss with its client the appropriateness of taking a potential upgrade and its impact on existing workflows and the user interface. Ultimately, the decision on whether to take a particular code or configuration enhancement remains with the client and can involve clinical and commercial considerations.” Source location Response from Oracle
Open published response
Concerns raised 1 Failure of the medication-ending alert system to draw attention to prescription review when no prescribing clinician accesses the patient’s record View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William Richard STOCKIL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Richard Stockil was admitted to hospital after being found on the floor at home following a long lie, with rhabdomyolysis and dehydration. An electronic prescription error and ineffective alerts resulted in his antibiotics stopping before further antibiotics were prescribed when signs of infection developed; he died from pneumonia. The report identified a risk that medications may cease when they should be continued if no prescribing clinician accesses the patient’s records.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the medication-ending alert system to draw attention to prescription review when no prescribing clinician accesses the patient’s record
Wider context from the report “The system has been changed since the death of Mr Stockil in that alerts of medication ending are now only sent to clinicians who have the right to prescribe in order that alerts are seen by the correct staff. It is no longer the case that the alerts can be sent to any clinicians who do not have the ability to address prescriptions.
The current version of the system generates alerts when anyone with a prescribing right accesses the patient’s records.
This means that an alert will only be shown to a prescriber and only if they access the patient’s records. Therefore, it was accepted that there was a risk that the alerting system would not operate to draw attention to the need for prescription review before the medication ceases if no prescribing clinician accesses a patient’s record .
This creates a risk that medications will cease when they should be continued and creates a risk of future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore with Royal Surrey whether configuration or other changes could facilitate adherence to the clinical workflow, including broadening alert recipients.
Verbatim wording from the response “19. Oracle Health considers that the anti-infective alert notification features are appropriate and functioning as designed. To the extent the Area Coroner’s concern relates to prescribers not accessing the EPR, this is respectfully an issue in the clinical workflow which cannot be addressed through further alert notifications. Nevertheless, Oracle Health will:” Source location Response from Oracle
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with Royal Surrey establishing an alert-notifications committee to review existing alerts and identify new alerts for development.
Verbatim wording from the response “19.2. More generally, Oracle will also discuss with RSFT the benefits of: (a) establishing an alert notifications committee as part of its healthcare information technology governance, to review existing alert notifications or identify new alert notifications for development; (b) defining, documenting and regularly reviewing how it works with alert notifications in digital solutions through a published Standard Operating Practice; and (c) working more closely with Oracle Health’s ‘Apps Services’ team for future configuration changes.” Source location Response from Oracle
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Alerts are appropriately displayed within patient records and cannot substitute for clinicians following established clinical workflows and standards of care.
Verbatim wording from the response “3.4. The alert notification system is not intended to serve as a substitute in place of the clinical protocol to access individual patient EPRs daily and it would be improper for it to do so. To the extent that there is concern about prescribers not accessing their EPR, this is a clinical workflow issue. Ultimately, no amount of alert notifications can address the shortcomings of a prescriber failing to follow a clinical workflow or not observing underlying standards of care.” Source location Response from Oracle
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Login-based or external email alerts are considered unworkable because they risk alert fatigue, workflow disruption, lost acknowledgement monitoring and data-security breaches.
Verbatim wording from the response “15.2. Electronic alert notifications must operate within the confines of the Millennium system and having alert notifications sent externally (e.g., by e-mail) would be less effective and risks unacceptable data security breaches.” Source location Response from Oracle
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No evidence indicates a software defect; Millennium was working as designed and configured, including subsequent independent modifications.
Verbatim wording from the response “3. While there is no suggestion that the software at issue was in anyway at fault or contributed to the Deceased’s death, Oracle Health conducted a review as described more fully in this Response and concludes as follows (key findings are highlighted in bold throughout):” Source location Response from Oracle
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The client retains responsibility for deciding whether to adopt code or configuration enhancements, including their clinical and commercial implications.
Verbatim wording from the response “D. POTENTIAL ENHANCEMENTS TO MEDICATIONS MANAGEMENT AS DEPLOYED AT RSFT” Source location Response from Oracle
Open published response
Concerns raised 1 Failure of Emergency Department software to provide quick and clear identification of patient acuity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Emily Kate Harkleroad · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emily Kate Harkleroad collapsed on 18 December 2022 and died from a pulmonary embolism in the early hours of 19 December 2022. The report states that failures and delays in treatment meant she did not receive anticoagulant treatment that, on a balance of probabilities, would have prevented her death. A further concern was that the Emergency Department’s new computer system lacked the previous clear RAG rating display for quickly identifying critically ill patients, particularly during periods of extreme pressure.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oracle Corporation UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department software to provide quick and clear identification of patient acuity
Wider context from the report “I 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. I understand that Cerner is now owned by Oracle Corporation. I 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. I heard evidence that the new Cerner software did not include such a system. I understand that, 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, I 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 my 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. I 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.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with CDDFT whether configuration changes can further support the Durham Emergency Department.
Verbatim wording from the response “19. Oracle Health is in discussions with CDDFT as to whether there are configuration changes that can be made to further support the Durham Emergency Department. In particular, Oracle Health has offered the following to CDDFT:” Source location Response from Oracle
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make the colour-coded Early Warning Score Risk Level enhancement available for deployment to CDDFT and other legacy deployments through the standard upgrade programme.
Verbatim wording from the response “4. Notwithstanding the above conclusion, that the Millennium software at Durham Emergency Department was working as designed, configured and approved by CDDFT, Oracle Health fully acknowledges the importance of the Assistant Coroner’s observations. In particular, the Assistant Coroner’s desire to ensure that there is a “quick and clear way of identifying the most critically ill patients”, especially “in times of extreme pressure” on Durham Emergency Department, including through the inclusion of a “RAG rating system”. Oracle Health has engineered a configuration enhancement, namely an additional colour coded column on Launchpoint’s homescreen charting individual patient’s ‘Early Warning Score Risk Level’. This enhancement will be available for deployment to CDDFT and other legacy deployments from around June 2024.” Source location Response from Oracle
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engineer a configuration enhancement adding a colour-coded Early Warning Score Risk Level column to the Launchpoint homescreen.
Verbatim wording from the response “4. Notwithstanding the above conclusion, that the Millennium software at Durham Emergency Department was working as designed, configured and approved by CDDFT, Oracle Health fully acknowledges the importance of the Assistant Coroner’s observations. In particular, the Assistant Coroner’s desire to ensure that there is a “quick and clear way of identifying the most critically ill patients”, especially “in times of extreme pressure” on Durham Emergency Department, including through the inclusion of a “RAG rating system”. Oracle Health has engineered a configuration enhancement, namely an additional colour coded column on Launchpoint’s homescreen charting individual patient’s ‘Early Warning Score Risk Level’. This enhancement will be available for deployment to CDDFT and other legacy deployments from around June 2024.” Source location Response from Oracle
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The client decides whether to adopt software or configuration enhancements, considering clinical and commercial factors.
Verbatim wording from the response “18. Oracle Health continuously engages in ongoing dialogue with its clients with regard to potential software code and configuration enhancements to its Millennium solutions. Such enhancements can arise at the global, or national, level in response to the knowledge and experience gained by Oracle Health from working with its extensive client base. They can also arise in response to specific issues at the level of local deployments. In each case, Oracle Health will discuss with its client the appropriateness of taking a potential upgrade and its impact on existing workflows and the user interface. Ultimately, the decision on whether to take a particular code or configuration enhancement remains with the client and can involve clinical and commercial considerations.” Source location Response from Oracle
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The software was working as designed and configured, and no evidence indicates that a software defect made the death preventable.
Verbatim wording from the response “3. While there is no suggestion that the software was at fault, and many factors contributed to the death of the Deceased, based upon Oracle Health’s review and the facts and matters described more fully in this Response, it concludes as follows (key findings in this Response are highlighted in bold throughout):” Source location Response from Oracle
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations