A 31-year-old woman died after A&E staff failed to give her "appropriate and timely" treatment for a blood clot in her lung, a new report from a coroner has revealed. 

Emily Kate Harkleroad collapsed on December 18, 2022, whilst out with a friend. Although she was rushed to the University Hospital of North Durham, she died in the early hours of December 19. 

Now, the coroner at an inquest into Emily's death has warned against issues with the new computer system at Durham Hospital and outlined a series of "errors and delays" prevented her from receiving the treatment that would likely have saved her life. 

The computer system was only introduced a few months before the much-loved young woman collapsed, and did not have the function to quickly identify patients that needed to be urgently seen by senior clinicians. 

The Northern Echo: The University Hospital of North Durham, part of the County Durham and Darlington NHS Foundation Trust

This meant that although pulmonary embolism - a blood clot in her lungs - had been identified as a likely diagnosis for Emily, she was not given the right treatment at the right time. 

Emily, who worked as an NHS dietician, was not given the anticoagulant treatment that she needed, and which the coroner concluded "would, on a balance of probabilities, have prevented her death."

Rebecca Sutton, assistant coroner for County Durham and Darlington, said: "I heard evidence that in or around October 2022 a new computer system was introduced into the Emergency Department of the University Hospital of North Durham.

 "Previous software in use in the Emergency Department included a “RAG rating” system, which ensured that the acuity of the patients was easily identifiable by looking at a single page on a display screen.

"I heard that the new Cerner software did not include such a system. I understand that, instead, the Cerner software has symbols next to patients’ names that, when clicked on, indicate the level of acuity of the patient, but are not a clear indication at first glance.

"In summary, I was told that the previous RAG rating system was an effective tool in quickly identifying patients requiring urgent oversight by senior clinicians, especially when the Department was under extreme pressure.

"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.

"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."

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The coroner believed that action needed to be taken to prevent others from dying in a similar way to Emily. 

The Prevention of Future Deaths Report was sent on to both the County Durham and Darlington NHS Foundation Trust and Oracle, which is the company that owns the software used by the hospital. 

Both organisations have to respond to the report by April 1, outlining "details of action taken or proposed to be taken", as well as a timetable for this action.