The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)
 
Gillian Peacock was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithomycin. It was recorded by a hospital pharmacist on 1st March 2023 in her medical notes that the use of these two drugs can cause digoxin toxicity and an alternative drug or monitoring is advised. No alternative drug was prescribed and no monitoring took place until 7th March 2023.
 
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.
 
I have a concern that the current system does not address the issue of important medical information being recorded in a patient’s notes not being accessible in such a way that clinicians can see and if necessary act on it.
 
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. In addition, that it can be accessed immediately without reliance on the verbal passing of information from one member of the treating team to another.

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