'MISSED' CHANCE
‘Much-loved’ woman, 31, died after ‘hospital’s new computer system delayed treatment for blood clot in her lung’
Including the assistant coroner's 'concerns' about the new computer system
AN NHS dietitian died after a hospital’s new computer system is thought to have delayed treatment for a blood clot in her lung.
Emily Harkleroad, 31, collapsed on December 18, 2022, and was taken to the University Hospital of North Durham, where she passed away the following morning from a pulmonary embolism – a clot on the lung.
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A coroner has now issued a warning over the new computer system, following Emily’s death.
The assistant coroner for County Durham and Darlington Rebecca Sutton said, on balance that her death could have been prevented.
She also noted computer system concerns had been raised by several clinicians.
County Durham and Darlington NHS Foundation Trust (CDDFT) said it took the coroner’s report extremely seriously.
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An inquest into the death of Emily, who had previously worked for the trust as a dietitian, was opened on January 6, 2023, and concluded on January 17, 2024.
While staff recognised that a pulmonary embolism was the likely diagnosis, the inquest heard “errors and delays” in her treatment resulted in her not receiving the anticoagulant or blood thinning treatment, that she needed quickly enough.
'SERIOUS CONCERNS'
Ms Sutton said she had “serious concerns” about a new computer system introduced in the hospital’s emergency department.
She believed there was a risk that future deaths could happen unless action was taken.
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The hospital’s previous system in the department included a red, amber and green (RAG) alert system which quickly identified to doctors which patients needed urgent care.
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Ms Sutton said the new Cerner computer software did not have this alert system.
Instead, the software had symbols next to patients’ names that clinicians had to click to see how urgently they needed care, which meant there was no clear indication by simply glancing at it.
The trust had started using the new IT system in October 2022, two months before Emily died.
Ms Sutton added the previous RAG rating system was “particularly effective” in times of extreme pressure in the emergency department as it was a quick and clear way of identifying the patients in most need.
We will be responding to the coroner within the required timescales and it would be inappropriate to comment further whilst that process is ongoing
Spokesperson
She also said it was an important tool that could prevent deaths in the future.
The assistant coroner added concerns about the new IT system which had been raised by various clinicians but the response had been it did not have that functionality.
DEMANDING ACTION
The coroner has written to the hospital trust demanding action, giving it 56 days to explain what steps are being taken.
A spokesperson for County Durham and Darlington NHS Foundation Trust said: "We send our sincerest condolences to Emily’s family and take the findings of this report extremely seriously.
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"We will be responding to the coroner within the required timescales and it would be inappropriate to comment further whilst that process is ongoing."
Oracle Corporation bought Cerner Corporation in December 2021.
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