Source · Prevention of Future Deaths
Thomas Taylor
Ref: 2014-0388
Date: 1 Sep 2014
Coroner: ME Hassell
Area: London Inner (North)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified a lack of clear leadership and sufficient staffing on the ward. Additionally, there were no clear protocols for handling lost patient notes or for managing blood sugar monitoring, insulin administration, and escalation of care for hyperglycaemic patients.
Date
1 Sep 2014
56-day deadline
27 Oct 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner identified a lack of clear leadership and sufficient staffing on the ward. Additionally, there were no clear protocols for handling lost patient notes or for managing blood sugar monitoring, insulin administration, and escalation of care for hyperglycaemic patients.
View full coroner's concerns
contained within the narrative attached, but in brief -
1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support.
On 21 February, a bank nurse worked alone in the morning, though was joined by another agency nurse at lunch time, with only a senior nurse in the office.
On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients.
Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse.
There was a conflict of views among the nurses that day about who had primary care of Mr Taylor.
2. There was no protocol for the loss of notes and drug chart. Attempts by the ward staff to locate these were not prompt, focused or sustained. The notes and chart were later found simply in a drawer on the ward.
3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff.
1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support.
On 21 February, a bank nurse worked alone in the morning, though was joined by another agency nurse at lunch time, with only a senior nurse in the office.
On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients.
Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse.
There was a conflict of views among the nurses that day about who had primary care of Mr Taylor.
2. There was no protocol for the loss of notes and drug chart. Attempts by the ward staff to locate these were not prompt, focused or sustained. The notes and chart were later found simply in a drawer on the ward.
3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff.
Report sections
Investigation and inquest
On 27 March 2014 I commenced an investigation into the death of Thomas Charles Taylor, aged 54 years. The investigation concluded at the end of the inquest earlier today. I made a narrative determination, which I attach to this letter.
Circumstances of the death
Mr Taylor was a diabetic who died in the Royal Free Hospital after a delay in the administration of insulin, following the loss of medical notes and drug chart.
Copies sent to
Professor Dame Sally Davies, Chief Medical Officer for England
Similar PFD reports
Report details
- Reference
- 2014-0388
- Date of report
- 1 September 2014
- Coroner
- ME Hassell
- Coroner area
- London Inner (North)
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: 27 Oct 2014 (estimated from the report date).
Sent to
- Royal Free London NHS Trust
Part of a series
2015-0076
0 responses identified