Eliza Bowen

On 25 November 2014, I commenced an investigation into the death of Eliza Rebecca Bowen. The investigation concluded at the end of the inquest on 20 April 2015. The conclusion of the inquest was the deceased died on the 15 November 2014 from la. Hyperosmolar non-ketotic coma and this was a natural cause of death.

Eliza Bowen was admitted as a resident at the Springfield House Care Home on the 18 August 2014. She had a medical history including previous sub arachnoid haemorrhage, shunt in situ, hypertension and had suffered a CVAlstroke. Her medical needs were complex and she had limited communication and was fed via a gastrostomy or PEG tube. She was effectively immobile.
2. Her medication and care needs were managed and a detailed care plan was drawn up to cater for her needs. This also included regular contact with the General Practitioner for medical advice. There was no previous history of diabetes and previous blood glucose levels were within the normal range.
3. On the 15 November 2014. she became suddenly unwell and was admftted to New Cross Hospitai. VVoiverhampton with significantly raisea glucose levels (o mmo/i1 In hospital she was diagno.sed with acute Kidney niury and raiseo urea and creatimne. Desnite medical intervention, she died as result of
—etaoc ‘cala’ces o ogbt ado o a ca’a c cease ‘er c giucose. This condition is called hyperosmolar nonketotc coma and is recognised as a life threatenng emergency in diabetics.
4. Dunng the course of the inquest evdence emerged that she may have recently developed diabetes in the last few months before her death. Her family described that a few days before her admisson to Hospital she appeared drowsy and sleepy and less responsive than normal. However her last recorded reading for blood glucose taken at Hospital on the 27.11,1.3 was raised when a reading of 9.9mmoIiL was recorded. This may iave been an indication of pre diabetes condition and she had known risk factors including a BMI greater than

5. There was no follow up blood ucose monitonng throughout 2014 because 1 there was no indication she was diabetic However, she was regularly monitored throughout 2013 and for reasons which remain unclear no blood glucose tests were performed in 2014 ONER’S CERNS
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-———H During the course of the inquest the evidence revealed matters giving rise to concern In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you The MATTERS OF CONCERN are as follows.
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