Recurance · prevention of future deaths reports
Pre-inquest brief
Patient record system fails to display critical clinical information
The earlier warning
Agnes Sansom · 7 Jan 2020 · Jeremy Chipperfield, County Durham and Darlington
“existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it”
judiciary.uk/prevention-of-future-death-reports/agnes-sansom
What was promised
Stated action 1 · response to Agnes Sansom (7 Jan 2020) · stated timescale: none stated
“The root cause analysis report has been reviewed and we have concluded that a misleading choice of words have been used as follows:”
judiciary.uk/…/2020-0002-Response-from-County-Durham-and-Darlin…
What recurred
- 5 Jun 2024 · Gillian Peacock · James Thompson · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Agnes Sansom · 7 Jan 2020
“existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it”
Later · Gillian Peacock · 5 Jun 2024
“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.”
What happened next
No web check of the stated actions has been published for this chain.