Source · Prevention of Future Deaths

Colleen Fletcher

Ref: 2022-0308 Date: 20 Jul 2022 Coroner: Fiona Butler Area: Rutland and North Leicestershire Responses identified: 1 / 2 View PDF

Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services attend.

Date 20 Jul 2022

56-day deadline 14 Sep 2022

Responses identified 1 of 2

Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

I understand that patients who have volatile glucose levels have the availability of pre-issued prescriptions for rapid acting insulin. Those patients, like Mrs Fletcher, whose glucose levels are relatively stable don’t have the availability of the same prescription. Should their glucose levels begin to rise they would have to be referred to a GP, reviewed by that GP, possibly asked to monitor further and/or a prescription issued and collected from the surgery/chemist, before increased insulin could be administered. I was told that this could take in excess of a 24 hour period, during which time a patient’s glucose levels could continue to rise. I was told that raised glucose levels in and of themselves would not be considered an emergency for the ambulance service until a patient went into a state of hyperglycaemic collapse, which, as in the case of Mrs Fletcher, was a point of no return. I understand that discussions are taking place to ensure the availability of fast acting insulin to be prescribed for all patients who are diabetic (regardless of volatility in their blood glucose levels) and that whilst progress has been made for those whose readings are volatile there is still work to be done to have the standby provision of bolus injections available for patients otherwise stable, whose glucose levels could at any point become unstable (by contracting an infection for example). I consider that this is an essential tool for nurses on the front line to have at their disposal in treating effectively rising glucose levels and preventing hyperglycaemia and subsequent death.

Responses

1 respondent

Leicester Leicestershire and Rutland Integrated Care Board

16 Sep 2022 PDF

Action Planned

The ICB has established a task and finish group to review the clinical pathway for management of Hyperglycaemia in Care Homes. The ICB plans to trial new rapid acting insulin guidance, review the existing insulin authorisation form, and support the development of a business case to expand the use of continuous glucose monitors devices for patients in care homes. (AI summary)

View full response

Dear Miss Butler,

Re: Regulation 28 following the death of Colleen Alice FLETCHER

I write on behalf of (Chief Nursing Officer, NHS Leicester, Leicestershire and Rutland Integrated Care Board) in response to the Regulation 28 Notice issued to the NHS Leicester, Leicestershire and Rutland Integrated Care Board (“LLR ICB” or “the ICB” hereafter) following the investigation into the death of Colleen Alice Fletcher. The concerns highlighted by the Court are summarised as follows:

Availability and pre-issue of rapid acting (Bolus) insulin for patients whose glucose levels are relatively stable but who may experience unstable blood glucose readings at a specific time for which Bolus insulin may be required (for example if they have an infection).

The ICB hopes that the coroner’s concerns are addressed by the response set out below.

As a commissioner of healthcare, LLR ICB works in collaboration with primary care service providers (including GP Practices), and community and acute providers to continuously look for ways to improve provision of healthcare for our patient population across Leicester, Leicestershire and Rutland. This includes the provision of healthcare for diabetic patients.

The ICB has established a Leicester, Leicestershire and Rutland wide task and finish group to review the existing clinical pathway for management of Hyperglycaemia in Care Homes. This task and finish group draws on clinical experts across the system specialising in diabetic care and includes:
• Consultant in Endocrinology and metabolic medicine (University Hospitals of Leicester NHS Trust)
• GPs with a specialist interest in diabetes care and care homes
• Lead specialist diabetes nurse - inpatient and community team (University Hospitals of Leicester NHS Trust)
• Community nursing team (Leicestershire Partnership NHS Trust)
• Managerial commissioning leads for diabetes and care homes (NHS Leicester, Leicestershire and Rutland Integrated Care Board)
• Clinical educator (Leicestershire Partnership NHS Trust)
• Eden training team (Leicester Diabetes Centre) From the office of: , Chief Nursing Officer and Deputy CEO

Based At: County Hall, Leicester Our Ref: Your Ref:

The key aims and objectives of establishing this group includes:

Action Start date Completion date Notes
1. To review and improve the existing pathway and guidance for the LLR Management of Hyperglycaemia in care homes August 2022 End of September 2022 Next meeting to finalise the pathway 29/09/2022
2. To update and circulate the amended pathway and associated guidance and ensure the patient pathway is available for all staff in an easy-to-follow flow chart. 1st October 2022 15th October 2022

3. To develop a communication plan to embed the revised pathway among health care professionals and care home staff. This will include providing, 1st October 2022 - 15th October 2022

a. Clarity to staff in all settings on their responsibilities for the management of diabetic care

b. appropriate training and support for health care professionals and care home staff so that they are to be able to identify and manage care home residents that are experiencing raised blood sugars.

August 2022 March 2023 A series of training via roadshows currently in progress. Training for improving diabetic care in care homes had already been identified as a priority for 2022-23
5. Prioritising availability and administration of rapid acting insulin for the patient where it is deemed necessary by linking the pathway to our existing Home First service for a faster response. Home First is our expert rapid response team that are on hand within two hours to help keep older people well at home and avoid hospital admissions, this will ensure that diabetic care home residents who are experiencing an episode of unstable glucose will receive administration of insulin bolus within 2 hours of a referral. 1st October 2022

15th October 2022 Started and in progress. Home First have agreed to support and will be embedded into the revised pathway.
4. Review the existing insulin authorisation form and make it mandatory for primary care and hospital clinicians to use Insulin authorisation forms to quality assure safe prescribing of insulin including authorisation for bolus insulin in the community.

Insulin requests will only be accepted with the completion of the revised insulin authorisation forms which will include frailty scores and the recommended PRN rapid acting insulin dosage guidance depending on the patient’s frailty score and continuous blood glucose reading. September 2022 Mid - October 2022 Started and in progress - revised form has agreed with Leicestershire Partnership Trust. Authorisation forms now include that every patient on insulin will have the prescribing of ad-hoc rapid acting insulin written into their record.
6. Supporting the development of a system wide business case to access funding to expand the use of continuous glucose monitors devices for patients in a care home who are living with diabetes. This will assist the care home staff with monitoring and management of their resident’s glucose levels on a day-to-day basis. June 2022 October 2022 Business case in development for submission for system review in October 2022
7. Further scope any gaps in support / guidance to care homes for the effective management of patients with diabetes and look to access service development funding for a pilot project

Aug 2022 Nov 2022 Started and in progress. Aim for all work relating to improving insulin management and support to care homes to be completed by Nov 2022

I hope that this information is helpful in responding to the concerns raised.

Please do not hesitate to contact me or should you need any further assistance.

Report sections

Investigation and inquest

On 30 June 2021 I commenced an investigation into the death of Colleen Alice FLETCHER aged 82. The investigation concluded at the end of the inquest on 30 June 2022. The conclusion of the inquest was natural causes.

Circumstances of the death

Colleen Fletcher was diagnosed with Type 2 diabetes in 1999. She was insulin dependent. Due to her underlying condition of Alzheimer’s disease, Mrs Fletcher was cared for in a residential care home and her insulin was managed daily by the community nursing team. On 26 January 2021, Mrs Fletcher’s blood glucose levels began to rise and continued to do so over the course of the next few days, measuring 13.2 mmols on the 27 January and 17.2 mmols on 28 January. It did not respond to the prescribed insulin doses which were being administered. Mrs Fletcher was not referred to the GP or the Diabetic Specialist Nurse. On 29 January 2021 Mrs Fletcher’s blood glucose level was 29.6 mmols. She became hyperglycemic and collapsed. An ambulance was called but Mrs Fletcher went into a diabetic coma before the Ambulance arrived and sadly passed away at 10.31 hrs on 29.01.2021 at the Hinckley Park Care Home.

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Report details

Reference: 2022-0308
Date of report: 20 July 2022
Coroner: Fiona Butler
Coroner area: Rutland and North Leicestershire

Responses identified

Responses identified 1 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 Sep 2022.

Sent to

Executive NHS Leicester

Leicestershire and Rutland Integrated Care Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.