Gillian PEACOCK · Prevention of Future Deaths report

On 15/03/2023 09:42am investigation was commenced into the death of Gillian PEACOCK 16/08/1962 00:00. The investigation concluded at the end of the inquest on 05/06/2024 00:00. The conclusion of the inquest was that Gillian Peacock died on 8th March 2023 at Darlington Memorial Hospital. She suffered from a number of health conditions, but significantly atrial fibrillation for which she was prescribed digoxin. She was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithromycin. 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 where results showed an elevated level of digoxin. Her digoxin was withheld. She had displayed no recognised symptoms of digoxin toxicity during her stay in hospital. She suffered a cardiac arrest on the morning of 8th March 2023 and died. Post Mortem examination could not ascertain a cause of death. The medical evidence cannot on the balance of probabilities determine the contribution of digoxin & clarithromycin to her death..

Gillian Peacock died on 8th March 2023 at Darlington Memorial Hospital. She suffered from a number of health conditions, but significantly atrial fibrillation for which she was prescribed digoxin. She was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithromycin. 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 where results showed an elevated level of digoxin. Her digoxin was withheld. She had displayed no recognised symptoms of digoxin toxicity during her stay in hospital. She suffered a cardiac arrest on the morning of 8th March 2023 and died. Post Mortem examination could not ascertain a cause of death. The medical evidence cannot on the balance of probabilities determine the contribution of digoxin & clarithromycin to her death.

Gillian Peacock was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithromycin. 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.