Inquest finds '˜gross failure' at Blackpool hospital after death of diabetic grandad
The son of a diabetic man who died after doctors failed to give him insulin has said he hopes nobody else ever has to suffer what his family has gone through.
A coroner ruled ‘neglect’ contributed to Barry Thompson’s death at Blackpool Victoria Hospital after hearing staff failed to monitor him properly or pass on vital information about his condition.
Assistant coroner Clare Doherty said there was a ‘gross failure’ by staff who cared for the 70-year-old, of Washington Avenue, who died of natural causes.
Matron Sue Roberts, who took over A&E following Mr Thompson’s death, apologised, telling the family: “We did not give your dad, your brother, your grandad, the insulin.”
Mr Thompson’s son Mark, 51, told The Gazette: “My dad has gone but if this stops someone else going the same way then something has come out of it.”
Mrs Doherty said she does ‘not criticise or point fingers at any one person’, but ruled there was a ‘failure to pass on vital information’ about Mr Thompson, of Washington Avenue in Blackpool.
She said: “There was a failure to monitor him and there was a failure to test for ketones from 4pm until the time he died. I do find that a gross failure.
“It is not my intention to try and punish but to fairly sum up what has happened here, and the cause of death I will be recording is death by natural causes contributed to by neglect.”
Ms Doherty, who said another patient died in similar circumstances, issued a rare regulation 28 letter, aimed at preventing more deaths, to hospital bosses, who have outlined several changes that have been made.
She added: “Mr Thompson’s death has been rendered unnatural because it would not have occurred but for some human failing.”
Mr Thompson was taken to A&E by ambulance at 12.29pm on February 27 last year, suffering from confusion and a foot infection, an investigation launched by the hospital found.
The serious incident report said Mr Thompson was seen by a doctor at 4.52pm, and it was noted he had not had his morning dose of insulin, the first of two he had daily for Type 2 diabetes.
At 7.37pm, he was admitted to the acute medical unit (AMU), where he was found unresponsive by a nurse at 1.55am the following morning.
Mr Thompson was found to have died from diabetic ketoacidosis – a build-up of dangerous chemicals caused by a lack of insulin – and septicaemia, and diabetic foot ulcers.
A long-term poor control of diabetes and obesity were secondary factors.
Ms Doherty told the court: “I have considered why Mr Thompson went on to develop diabetic ketoacidosis. I know there was a high volume of patients being received by the emergency department that day, and it did place great demands on the beds and the staff, and that devolves to the wider hospital.
“However, there were three ways of passing information to the ward from the emergency department about a patient. All three fell down. Important information was not communicated.”
The court was told nurses in both departments should have had a verbal handover. There was no record of a conversation and no nurse ‘recalled being involved in that part of the handover’.
A handover document was found to be ‘incomplete’, the inquest heard, while a computerised tracking system did not mention Mr Thompson ‘had diabetes, that he needed insulin, and that he needed monitoring’.
Ms Doherty said: “The opportunity to understand the totality of Mr Thompson’s problems and to understand he had diabetes and needed monitoring as well as having sepsis was lost.
“There must however have been a realisation during the course of the evening because at some point – it is not clear from the records – the nurse in charge starts to ask for blood sugar levels and she looks for a ketone testing box.
“She did look for a ketone box, she says, but she was unable to find out. I did hear evidence that there was one broken on the ward and the other was in use, but there were other boxes
available in the hospital.”
The two-day hearing heard from one clinician who described Mr Thompson’s death as ‘avoidable’, though Ms Doherty said ‘there may not have a chance to stop’ his sepsis.
“But he was then clear that Mr Thompson died when he did not because of the sepsis, but because of the unchecked diabetic kesoacidosis,” she added. “I do not think any witness has disagreed with him.
“We are not talking about complex treatment. What was needed was fundamental healthcare. What was needed was information sharing, coordination, and monitoring.
“We have learned that ketones can be checked quite quickly and quite easily. They can be checked using blood, they can be checked using urine.
“We know test results can be produced almost contemporaneously. That is not to say that if monitoring had been done it would have dictated a certain cause of action, but the opportunity was lost.
“The condition progressed unchecked.”
Matron Sue Roberts, who took over A&E following Mr Thompson’s death, admitted that, despite being made a high priority patient by a triage nurse in A&E, he was not seen within 60 minutes by a doctor as he should have been.
She told the court 14 patients were waiting to be admitted at 9.30pm on February 26, with 20 people waiting for a bed at 7am the following day.
“Throughout the day there was always 34 patients in that area of the department and the medical take for the day was 58, with 41 patients transferred from A&E to AMU,” she said.
AMU also took 10 patients from other areas, such as GPs.
Ms Roberts said: “This year, winter has never left the hospital at all. We have been hit every day with high volumes of patients coming through. It has never gone down in the summer months. Historically, that has happened.”
But she told Mr Thompson’s family, who were in court for the hearing: “I sit here and apologise to you. We did not give your dad, your brother, your grandad, the insulin.”
The hospital’s medical director, Prof Mark O’Donnell, told the coroner’s office in a letter several changes have been made.
He told Alan Wilson A&E has reviewed its triage to ensure patients are given clinical pathways ‘in a timely manner’, and said new guidance for the management of diabetes ketoacidosis was formally launched in A&E, AMU, and on the diabetic and endocrinology ward on last Wednesday, documents revealed.
An insulin prescription chart was produced and trialled, and the hospital launched a ‘comprehensive training’ programme for its handover processes.
More than a dozen extra staff members have also been recruited to work in A&E, Prof Mark O’Donnell said.
“This increase in staffing levels will be reviewed on a month-by-month basis to monitor benefits and improvements in patient care and patient experience,” he wrote.
“So far our analysis has shown, since August, we have seen a reduction in the incidents reported and an increase in the number of patients who would recommend the service.”
Mr Thompson’s son Mark, 51, told The Gazette: “My dad has gone but if this stops someone else going the same way then something has come out of it.
“All he needed was his insulin. He had a bag in a cupboard less than four feet away with it in.
“They were absolutely brilliant in A&E but all communication went down when they transferred him.”
A spokesman for Blackpool Teaching Hospitals NHS Foundation Trust said: “We again offer our sincere condolences to Mr Thompson’s family.”