Coroner issues warning over hospital's new computer system after 'preventable' death of NHS dietician who died following 'errors and delays' to treatment for lung blood clot

• Emily Harkleroad died at University Hospital of North Durham in December 2022
• 31-year-old had been diagnosed as probably having a Pulmonary Embolism

A coroner has issued a warning over a hospital’s new computer system after the ‘preventable’ death of a 31-year-old woman.

Emily Harkleroad collapsed when out with a friend and died hours after arriving at the University Hospital of North Durham following ‘errors and delays’ in her treatment.

The NHS dietician was diagnosed as probably having a Pulmonary Embolism – a blood clot in the lung – but died after she failed to receive the treatment she needed and which probably would have saved her life, the coroner concluded.

Rebecca Sutton, the assistant coroner for County Durham and Darlington, has now issued a ‘prevention of future deaths report’ to highlight a problem with the hospital IT system that could lead to future tragedies unless action is taken.

The new hospital computer system was launched in October 2022, two months before the tragedy in the emergency department on December 19, 2022.

Emily Harkleroad collapsed when out with a friend and died hours after arriving at hospital following ‘errors and delays’ in her treatment

The inquest into Miss Harkleroad’s death heard that unlike the previous IT system the new one didn’t have a clear way for senior doctors to identify the patients that needed the most urgent treatment at a glance.

With the new software doctors had to click on symbols next to the patient’s name to get the same information.

The coroner stated in her report: ‘It is my view that, especially in times of extreme pressure on the Emergency Department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.’

This ‘RAG rating’ system, which ensures the criticalness of each patient is ‘easily identifiable by looking at a single page on a display screen,’ was discussed at the inquest in January.

Ms Sutton indicated the complaints by staff about the change had gone unheeded.

She said: ‘I was told that concerns about the absence of a RAG rating type system had been raised by a number of clinicians, but that the response, thus far, had been that the new system does not have that functionality.’

The coroner recorded a ‘narrative conclusion’ that stated death was due to natural causes. However, on a ‘balance of probabilities’ her death ‘would have been preventable had appropriate medical treatment been provided.’

Ironically, Miss Harkleroad worked for the same NHS trust – County Durham and Darlington NHS Foundation Trust – that dealt with her care. They have now been sent the report by the coroner.

The trust and Oracle Health UK – who now own the new IT system – have been asked to take action to prevent future deaths. They have been told to reply with details of action taken or planned within 56 days.

Miss Harkleroad, who lived in Durham, was taken to hospital by ambulance after collapsing on December 18, 2022.

The coroner’s report said staff recognised that Pulmonary Embolism – a serious and potentially fatal condition – was the ‘likely diagnosis’ but there were failures to provide her with ‘appropriate and timely treatment.’

Specifically, ‘errors and delays’ meant she never received the anticoagulants or ‘blood thinning’ drugs she needed, ‘which would, on a balance of probabilities, have prevented her death,’ the coroner ruled.

Miss Harkleroad died in University Hospital of North Durham (pictured) during the early hours of December 19

Miss Harkleroad died in hospital during the early hours of December 19. Her family have declined to comment.

The NHS trust launched its new Electronic Patient Record system (EPR) in October 2022.

Described as a ‘massive undertaking,’ the new digital technology was intended to give ‘clinicians faster access to more accurate information transforming healthcare delivery’ across the region.

The IT system was designed to improve patient record sharing and enable medical records to be accessed by everyone involved in a patient’s care.

Medical Director Jeremy Cundall said at the launch it was an IT tool ‘that we can use to provide safe, seamless and efficient care’.

But since then there have been other problems with the IT system, such as issues it has caused with mortality data.

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.

‘We will be responding to the Coroner within the required timescales and it would be inappropriate to comment further whilst that process is ongoing.’

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