Dear Mr Appleton

Inquest into the death of Mr John Cogdon and response to your Report to Prevent Future Deaths (PFD) We write further to the above Inquest and in response to your report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 15 November 2024, issued to South Tees Hospitals NHS Foundation Trust. You advised that at the hearing on 8 November 2024, you heard evidence that different wards and departments within the James Cook University Hospital, Middlesbrough utilise different record-keeping and prescribing systems (including paper based and electronic based systems). Whilst we appreciate the decision to issue a PFD to the Trust is a judicial decision for you to make if you feel the threshold has been met, we advised in our letter of 11 November 2024 that we did not feel that you had been provided with sufficient information relating to the Trust’s current position with regard to the electronic systems for you to consider. We can only apologise that this information was not available at the Inquest.

We fully acknowledge that the electronic prescribing system has not been introduced into the critical care areas in South Tees. This is related to the requirement for a major refurbishment project in CICU which is likely to be completed in early 2026. You were concerned that the Trust’s record keeping and prescribing systems were fragmented and lacked integration. We would like to respond to your concerns in full. 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. The benefits of introducing an ePMA system are widely recognised to improve patient safety through a reduction in medication errors. Within this Trust we have found that improvements have been made in the following areas:
• There has been a 17% reduction in prescribing errors in comparison with previous audits relating to incorrect time/frequency/route
• Antimicrobial stewardship audits have shown improvement: indication of treatment has improved from 82% to 94%, review date 76% to 100%, 100% compliance allergy status
• Improvement in prescribing in line with clinical guidelines due to drug order sets customised build within the ePMA
• Rapid tranquilisation audit demonstrated a 50% improvement with the use of ePMA
• Insulin prescribing compliance has increased from 25% compliance with guidance to 100% compliant Additional benefits to medication safety are as follows:
• Medication records are stored electronically and are available 24/7 and can be accessed remotely
• Patient’s medication history, decision support and online resources available to aid prescribing, with allergies and interactions highlighted
• The system will give extensive and robust audit information on medicines usage.
• A live electronic medication safety dashboard has been developed for omitted doses, VTE prescribing and critical medicines.
• Lab results are now integrated into Miya and is visible in the drug chart
• Clinical decision support now in place
• Customised warnings, hard stops and maximum prescribing doses are now in place In addition to ePMA, improvements have been apparent in other patient safety mechanisms which are in place in relation to medication:

• 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.
• 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
• The Trust has introduced new and innovative roles to release capacity for clinical teams; this includes a ward medicines assistant in Cardiology
• At the time of Mr Cogdon’s admission (June 2023) 1% of patients were seen by the clinical pharmacy cardiothoracic 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
• 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.

We would like to address the concerns raised by the witness that there is no linkage between the ward and ITU systems. We also note the findings of the Mortality review: (the fact that MIYA was only available on some wards is an issue – transcription errors between MIYA and drug charts noted… Omission of Lansoprazole a factor in his death because of the Gastrointestinal Bleed (GI) but it was the HIT that compromised his medical management). In order to address these concerns, we will initially outline Mr Cogdon’s journey through the hospital departments describing which medications were prescribed and on which system, how they were transcribed and subsequently administered, and at which points there were errors and omissions within this process. 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.

Mr Cogdon was transferred to theatre on 26/6/23. The usual process is for an anaesthetist to review the drug chart and prescribe post-operative medications. Patients who are transferred to the cardiothoracic intensive care unit post operatively would usually have PPI prescribed throughout their stay and reviewed daily on the consultant-led morning ward round. However, no PPI was prescribed for Mr Cogdon during the post-operative period although Lansoprazole is noted on the anaesthetic chart in the list of regular medications. This was a prescribing omission unrelated to ePMA.

On 30/6/23 regular PPI IV Omeprazole was prescribed to Mr Cogdon but was intentionally not given and was replaced with Pantoprazole 40mg twice daily in line with the Trust’s GI bleeding protocol. This was commenced on 1/7/23 for 72 hours due to duodenal bleeding with subsequent Lansoprazole 30mg prescribed twice daily until 11/7/23. On readmission to cardiothoracic intensive care unit there was a reduction in Mr Cogdon’s dose of Lansoprazole to 30mg once daily. It is not clear whether this was a deliberate reduction given that Mr Cogdon had received 10 days of high dose treatment or whether this was a transcription error. The opinion of a senior Gastroenterologist was that 10 days of high dose treatment was acceptable practice.

On 25/7/23 Lansoprazole was switched to Pantoprazole 40mg twice daily, this dose was then reduced to once daily on 26/7/23 and increased back to twice daily on 28/7/23. Lansoprazole 30mg twice daily was then recommenced on 31/7/23.

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. We would like to thank you for highlighting this matter of concern, and for giving us the opportunity to respond. We hope this response provides you with assurance that your concerns have been addressed by the organisation. On behalf of the Trust, we would once again like to express our sincerest condolences to Mr Cogdon’s family.