John COGDON · Prevention of Future Deaths report

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Issued 15 Nov 2024•Teesside and Hartlepool

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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

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

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. South Tees Hospitals NHS Foundation Trust

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

  2. South Tees Hospitals NHS Foundation Trust

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

  3. South Tees Hospitals NHS Foundation Trust

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

  4. South Tees Hospitals NHS Foundation Trust

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

  5. South Tees Hospitals NHS Foundation Trust

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

  6. South Tees Hospitals NHS Foundation Trust

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

  7. South Tees Hospitals NHS Foundation Trust

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. South Tees Hospitals NHS Foundation Trust

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

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. South Tees Hospitals NHS Foundation Trust

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

    Existing 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

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

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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

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

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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

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

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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

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

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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

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

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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

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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