A North East hospital has been criticised after a drug combination turned toxic in the days before the death of a 60-year-old patient. 

Darlington Memorial Hospital has been slammed in a coroner's report following the death of 60-year-old Gillian Peacock, from Bishop Auckland.

Ms Peacock, a mother of two, was admitted to the hospital in late February 2023, for treatment for a chest infection - but nine days later, she died, with toxic levels of a prescription drug in her system.

As well as her chest infection, Ms Peacock suffered from a number of preexisting health conditions, including atrial fibrillation, for which she was prescribed digoxin. 

When she was put on another drug, clarithromycin, the pharmacist noted that the use of these two drugs together can cause digoxin toxicity. 

The pharmacist advised that an alternative drug was used, or staff monitored her, but none of this was undertaken until March 7, when tests showed she had elevated digoxin levels. 

Though Ms Peacock has shown no symptoms, and her digoxin was withheld, she suffered a cardiac arrest the morning (March 8) and died. 

An inquest, heard by James Thompson, the coroner for County Durham and Darlington, heard that a post-mortem examination could not ascertain a cause of death.

The medical evidence cannot on the balance of probabilities determine the contribution of digoxin & clarithomycin to her death.

Though the coroner was unable to conclude that digoxin & clarithomycin contributed to her death on the balance of probabilities Mr Thompson raised concerns about Ms Peacock's care. 

In his report, Mr Thompson said: "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."

In spite of these improvements made at Darlington Memorial Hospital, the coroner outlined that he has "a concern that the current system does not address the issue" of important medical information being inaccessible. 

This could mean that clinicians cannot see it, and "if necessary act on it", Mr Thompson wrote in a Prevention of Future Deaths report. 

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He added: "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 so that relevant information is visible to those involved in care.

"In addition, that [relevant information] can be accessed immediately without reliance on the verbal passing of information from one member of the treating team to another."

The hospital trust is now under a duty to respond to the coroners report by July 31, 2024, with details of action they will take, or have proposed to take, setting out the timetable for action. 

County Durham and Darlington Foundation Trust were contacted for a comment but did not respond.