🟢 Serious concerns have been raised after the death of a vulnerable woman in a Sunderland hospital, following what a coroner described as “complete confusion” over medication.
Valerie Gibson, 64, died at Monkwearmouth Hospital in October 2023 after being admitted under the Mental Health Act. An inquest found she died from natural causes, contributed to by the use of antipsychotic medication.
Now, Sunderland’s senior coroner has issued a formal warning to Cumbria, Northumberland, Tyne and Wear NHS Trust, saying there is a risk of future deaths unless action is taken.
The coroner highlighted serious failures, including staff uncertainty over what medication Ms Gibson had been given, poor record‑keeping, and the fact that a coat returned to her was not checked for tablets, with extra medication later found in its pockets.
He also raised concerns about new nurses administering medication without proper supervision, inconsistencies between electronic records and medication cabinets, and occasions where records showed drugs had been given before they were even dispensed.
Although the coroner said these issues were not proven to have directly caused Ms Gibson’s death, he warned the system failures could easily lead to patients being over‑ or under‑medicated in future.
The NHS trust has 56 days to respond and outline what changes will be made. The trust said its thoughts are with Ms Gibson’s family and that it will review the concerns carefully.