PFD report

John COGDON · Prevention of Future Deaths report

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Issued 15 Nov 2024•Teesside and Hartlepool

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Fragmented and non-integrated record-keeping and prescribing systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Implement electronic medication-safety functions, including dashboards, laboratory-result integration, clinical decision support, warnings, hard stops and maximum-dose controls.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2024.
  2. Action

    Complete integration of the Better Medications electronic prescribing and medicines administration system in Cardiology.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing integration measures for hospital prescribing systems have addressed the concerns about safe and effective medication prescribing.

    Stated by South Tees Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Fragmented and non-integrated record-keeping and prescribing systems

Wider context from the report

“1. At hearing on 8 November 2024, I heard evidence that different Wards/Departments within the James Cook University Hospital, Middlesbrough utilise different record-keeping and prescribing systems (including paper based and electronic based systems). I am concerned that the Trust’s record keeping and prescribing systems are fragmented and lack integration. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Implement electronic medication-safety functions, including dashboards, laboratory-result integration, clinical decision support, warnings, hard stops and maximum-dose controls.

Verbatim wording from the response

“• A live electronic medication safety dashboard has been developed for omitted doses, VTE prescribing and critical medicines.”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 2 · response
Published 19 November 2024

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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 integration of the Better Medications electronic prescribing and medicines administration system in Cardiology.

Verbatim wording from the response

“The Trust commenced the gradual implementation and roll out of the “Better Medications” electronic prescribing and medicines administration (ePMA) system in July 2022. The Cardiology department commenced integration in March, and this was completed in April 2023. This is hosted inside a software portal provided by Alcidion called Miya Precision. This is a solution which digitises the process of prescribing and recording medication administered to inpatients within the Trust.”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 2 · response
Published 19 November 2024

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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 integration measures for hospital prescribing systems have addressed the concerns about safe and effective medication prescribing.

Verbatim wording from the response

“We would like to thank you for highlighting these matters of concern, and for giving us the opportunity to respond. It is the Trust’s position that we have taken the relevant steps to integrate the hospital systems used in the safe and effective prescribing of medication since Mr Cogdon’s admission. We hope this additional information provides you with assurance that any concerns you had during the Inquest have been addressed by the organisation. We are more than happy to discuss further if this would be helpful.”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 4 · response
Published 19 November 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Increase Cardiology clinical pharmacy capacity by adding two whole-time-equivalent medicines technicians.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2024.
  2. 2

    Achieve compliance with the clinical-pharmacy element of GPICS and establish the required critical-care step-down procedure.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2024.
  3. 3

    Expand the clinical pharmacy cardiac team’s seven-day service through the next medicines-reconciliation business-case phase.

    Stated by South Tees Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 November 2024.
  4. 4

    Deliver ePMA training and access for Cardiology anaesthetists, with 95% currently compliant.

    Stated by South Tees Hospitals NHS Foundation TrustStatus at responseThe respondent said that this action was partly complete when they made their response on 19 November 2024.
  5. 5

    Introduce a ward medicines assistant role in Cardiology to release clinical-team capacity.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Lansoprazole prescribing error and postoperative omission were unrelated to the electronic prescribing and medicines administration system.

    Stated by South Tees Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Increase Cardiology clinical pharmacy capacity by adding two whole-time-equivalent medicines technicians.

Verbatim wording from the response

“• There has been an increase in investment in the clinical pharmacy service- with an increase in the number of technicians in the Cardiology department by two whole time equivalents. This has released pharmacists’ capacity for medication reviews and has improved the medicines reconciliation rates that are completed within 24 hours of admission.”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 3 · response
Published 19 November 2024

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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

Achieve compliance with the clinical-pharmacy element of GPICS and establish the required critical-care step-down procedure.

Verbatim wording from the response

“• GPICS (Guidelines for the Provision of Intensive Care Services) is the definitive reference source for planning and delivery of UK Intensive Care Services. The Trust is now compliant in the critical care for clinical pharmacy element of GPICS and has the required step-down procedure in place”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 3 · response
Published 19 November 2024

Open published response

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

Expand the clinical pharmacy cardiac team’s seven-day service through the next medicines-reconciliation business-case phase.

Verbatim wording from the response

“• At the time of Mr Cogdon’s admission (June 2023) 1% of patients were seen by the clinical pharmacy cardiac team within 24 hours of admission. The rate has now increased to 45% and it is a priority within the next phase of the medicines reconciliation business case to expand the 7-day service”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 3 · response
Published 19 November 2024

Open published response

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

Deliver ePMA training and access for Cardiology anaesthetists, with 95% currently compliant.

Verbatim wording from the response

“• On review of current ePMA training compliance, 95% of cardiology anaesthetists had completed ePMA online training and had access to the system to view/prescribe medications.”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 3 · response
Published 19 November 2024

Open published response

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

Introduce a ward medicines assistant role in Cardiology to release clinical-team capacity.

Verbatim wording from the response

“• The Trust has introduced new and innovative roles to release capacity for clinical teams; this includes a ward medicines assistant in Cardiology”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 3 · response
Published 19 November 2024

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 Lansoprazole prescribing error and postoperative omission were unrelated to the electronic prescribing and medicines administration system.

Verbatim wording from the response

“On review of Better Medications electronic drug chart (Miya), Mr Cogdon’s initial dose of Lansoprazole was prescribed 30mg once daily for 1 day only on 20/6/23 until 21/6/23. Mr Cogdon had been taking this daily prior to admission alongside Clopidogrel 75mg once daily and Aspirin 75mg once daily. Lansoprazole, or an equivalent proton pump inhibitor (PPI), should have continued throughout his stay. This was a prescribing error which was not linked to ePMA.”

Source location

Response from South Tees Hospitals NHS Foundation Trust
Page 3 · response
Published 19 November 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026