Source · Prevention of Future Deaths
Pamela Pattison
Ref: 2015-0108
Date: 23 Mar 2015
Coroner: John Pollard
Area: Manchester (South)
Responses identified: 0 / 1
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Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded by patient transfer delays and under-resourcing for diabetes care.
Date
23 Mar 2015
56-day deadline
18 May 2015 est.
Responses identified
0 of 1
Coroner's concerns
Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded by patient transfer delays and under-resourcing for diabetes care.
View full coroner's concerns
_ From the evidence it was apparent that nurse training on wards M4 and A11 was deficient and their understanding of the importance and danger of Type Diabetes seemed to be limited at best: The nurses were unable to say why they had not escalated her care on a number of occasions. ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin' The consultant expressed the 'hope' that they would know this; but the evidence suggested the contrary: It was evident that the nursing staff on, for example; the surgical wards, did not have any specialist outreach nurse advice on such things as diabetes_ May 17th
There was an obvious need for additional consultant cover for Diabetes. was told that funding has been put in place to cover this, but as no one has been appointed to fulfil this vital role_ The specialist outreach Nurse Practitioner for diabetes was booked off sick for one month; and no 'cover' was in place to cover his absence There was either a lack of equipment or a lack of understanding by the staff as to what equipment was needed by them: The staff indicated that were unable to find 'ketone dipsticks' , for diabetic urine sampling: was told that in fact these are unnecessary in that ketone blood tests are now routine. Similarly was told they could not find any or sufficient cardiac monitors on the ward: Further evidence revealed there are in excess of 240 such monitors in the hospital but the relevant staff seemed unaware of this. were also unaware that could have used the ward based defibrillator for the same purpose: There was a considerable of approximately 12 hours in moving her to ward A3 after this had been deemed the appropriate place for her to be: No reason for this delay was offered: It was conceded by the 'Head of Risk' for the Trust; that there was a general under resourcing within the Trust for the care of patients with Diabetes
There was an obvious need for additional consultant cover for Diabetes. was told that funding has been put in place to cover this, but as no one has been appointed to fulfil this vital role_ The specialist outreach Nurse Practitioner for diabetes was booked off sick for one month; and no 'cover' was in place to cover his absence There was either a lack of equipment or a lack of understanding by the staff as to what equipment was needed by them: The staff indicated that were unable to find 'ketone dipsticks' , for diabetic urine sampling: was told that in fact these are unnecessary in that ketone blood tests are now routine. Similarly was told they could not find any or sufficient cardiac monitors on the ward: Further evidence revealed there are in excess of 240 such monitors in the hospital but the relevant staff seemed unaware of this. were also unaware that could have used the ward based defibrillator for the same purpose: There was a considerable of approximately 12 hours in moving her to ward A3 after this had been deemed the appropriate place for her to be: No reason for this delay was offered: It was conceded by the 'Head of Risk' for the Trust; that there was a general under resourcing within the Trust for the care of patients with Diabetes
Report sections
Investigation and inquest
On 31st January 2014 commenced an investigation into the death of Pamela Pattison dob 13th 1944.The investigation concluded on the 17th March 2015 and the conclusion was one of a Narrative Conclusion, The medical cause of death was Ia Aspiration Pneumonia following insertion of naso-gastric tube for nausea and vomiting consequent upon unstable diabetic control. 11, Brittle diabetes with diabetic nephropathy and diabetic neuropathy. Fractured neck of femur:
Circumstances of the death
On the 6th January 2014 she fell at her home address and broke her hip. She was admitted to Stepping Hill Hospital and was operated on for her fractured femur: She had numerous co-morbidities including Type Diabetes_ On the January her insulin doses were intentionally omitted due to mistaken assessment by one of the medical staff She was cared for by relatively junior medical and nursing staff when in fact she ought to have been cared for in the HDU: As a result her diabetic care was sub-optimal and various failings led to her being nauseous and tending to vomit; leading to her developing aspiration pneumonia.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
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Report details
- Reference
- 2015-0108
- Date of report
- 23 March 2015
- Coroner
- John Pollard
- Coroner area
- Manchester (South)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 May 2015 (estimated).
Sent to
- Stockport NHS Foundation Trust