Recurring concern

Unreliable diabetes care and management

First to latest report 7 Jan 2014 — 12 Jun 2025

Reports that mention this concern
14
Times this concern has been raised
23
Stated actions linked to this concern
27

What this concern includes

Includes failures of controls specifically dedicated to diabetes care and management, including access to specialist diabetic support, monitoring of glucose or ketones, recognition and escalation of deterioration, diabetic status communication, insulin access and other clinically necessary diabetes-management arrangements.

What is not included
  • Excludes generic staffing or out-of-hours service deficiencies unless they directly impair diabetes care and management.
  • Excludes failures concerning other clinical conditions or specialist services without a direct diabetes-care connection.
  • Excludes generic communication, training, documentation or escalation deficiencies unless they are specifically dedicated to diabetes care.
  • Excludes medication, wound-care or monitoring concerns where diabetes is merely incidental and the asserted unsafe condition belongs to a different named process.

Reports and published responses 14 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Cheshire

    AI-generated summary

    Simon HOCKENHULL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Simon Hockenhull died at home on 5 December 2024 after contracting lobar pneumonia, with underlying diabetes and diabetic gastro-enteropathy reducing his resilience. The report raises concerns that inconsistent interpretations of a 28-day supply as a “month” can delay repeat prescriptions for diabetic medication and devices, potentially leading to inconsistent medication use and serious health effects including diabetic ketoacidosis.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent definition of a month for diabetic medication supplies

    Wider context from the report

    “In the course of this inquest, I have heard that some diabetic medications and devices have a life span of 14 days. When two are prescribed, they therefore amount to a 28 day supply. I have heard that this can cause problems as there are some pharmacists who interpret a 28 day supply as a “month”, and that it can therefore be challenging to obtain a further prescription within the same calendar month. For patients who already have a complex relationship with their medication and monitoring regime, the challenges this causes can mean that they then do not take their medication as consistently as they need to. For patients with a diagnosis of diabetes, this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis. At the heart of the issue seems to be that a “month” is being inconsistently defined. Sometimes it means 28 days, sometimes it is a calendar month. The RCGP RPS “Repeat Prescription Toolkit” (October 2024) does not seem to address this issue, so it may be that prescribers and dispensers are unaware of this issue. ”

    Source location

    Simon HOCKENHULL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Specific prescription-duration guidance was outside the Repeat Prescribing Toolkit’s agreed scope, which was not intended as a clinical guideline.

    Verbatim wording from the response

    “At the time of drafting the RCGP RPS Repeat Prescribing Toolkit, the Toolkit working group (made up of practicing GPs, Clinical Pharmacists, Patients, GP practice staff, NHS England policy leads and regulators), had been informed that NHS England may be exploring work on prescription duration and so it was agreed that specific guidance on prescription duration was out of scope for the toolkit. The toolkit was never intended to be a clinical guideline and so would not have addressed the specific issues that you have highlighted in this case. Annex A of the Toolkit (page 87) details what was within and outside of the scope of the Repeat Prescribing Toolkit.”

    Source location

    Response from Royal Pharmaceutical Society
    Page 3 · response
    Published 19 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Medication-ordering risks are not usually linked to 28-day versus 30-day duration.

    Verbatim wording from the response

    “Whilst it is a risk that patients may forget to order their medication or order late or there is a delay in the prescription being issued from the GP practice or community pharmacy, it is not usually linked to the medication duration of 28 vs 30 days. It is worth noting that legislation permits the community pharmacist to issue an emergency supply of a patient’s regular medication following appropriate clinical checks.”

    Source location

    Response from Royal Pharmaceutical Society
    Page 4 · response
    Published 19 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Calendar-month dispensing is impractical because manufacturer pack sizes, licensing requirements and risks of splitting packs constrain supply.

    Verbatim wording from the response

    “Calendar months in the year would be 28, 29 (leap year), 30 and 31 days, but this would be unworkable as previously mentioned, medication pack sizes are determined by the manufacturer and the licensing is based on the pack size submitted. Splitting some packs means the pharmacy would be supplying ‘off label’ which can bring separate issues around that. Again, these will vary depending on whether they are a “calendar” pack or a standard pack.”

    Source location

    Response from Royal Pharmaceutical Society
    Page 4 · response
    Published 19 June 2025

    Open published response

  2. Hertfordshire

    AI-generated summary

    Megan Davison · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Megan Davison was found deceased at home on 4 August 2017 after hanging herself with the intention of ending her life. The report identified concerns about her discharge from mental health care, limited integration between physical and mental healthcare, the absence of recognised diagnosis and care pathways for Type 1 Diabetes with Disordered Eating and Diabetic Ketoacidosis, and incomplete information-sharing between healthcare providers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of integrated healthcare system for diabetes and eating disorders

    Wider context from the report

    “(b) At a local level in East and North Hertfordshire there is no integrated healthcare system for patients with diabetes and eating disorders as there is in the west of the county. ”

    Source location

    Megan Davison · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with regional partners to learn from national pilots and trial integrated T1DE pathways locally.

    Verbatim wording from the response

    “The ICB is working closely with NHS England’s regional mental health and transformation team, to learn from recent national pilots to trial pathways for T1DE patients and apply this within the Integrated Care System (ICS). The regional team have confirmed they are happy to work with the ICB to ensure any learning from the pilots, as well as relevant national guidance, can be incorporated into our local model. Locally, Mental Health commissioners lead an implementation group with membership from all ICB partners including primary care, community commissioning, regional teams, the voluntary sector, service users, and carers to support quality improvement and delivery of eating disorder services and physical health checks. This work will inform further pathway development and improve access to physical health services for people with serious mental health conditions.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Lead a multi-partner implementation group to improve eating-disorder services and physical-health checks.

    Verbatim wording from the response

    “The ICB is working closely with NHS England’s regional mental health and transformation team, to learn from recent national pilots to trial pathways for T1DE patients and apply this within the Integrated Care System (ICS). The regional team have confirmed they are happy to work with the ICB to ensure any learning from the pilots, as well as relevant national guidance, can be incorporated into our local model. Locally, Mental Health commissioners lead an implementation group with membership from all ICB partners including primary care, community commissioning, regional teams, the voluntary sector, service users, and carers to support quality improvement and delivery of eating disorder services and physical health checks. This work will inform further pathway development and improve access to physical health services for people with serious mental health conditions.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce ICB case-discussion support and establish a clearer provider escalation process, with access details due by November 2024.

    Verbatim wording from the response

    “Where necessary, the ICB (via its clinical teams) can help to organise case-based discussions. We are reinforcing the availability of this support and ensuring there is a clearer process for local providers to escalate cases to the ICB. If a patient is assessed as needing joint input from diabetes and mental health services, the ICB can convene a case conference as appropriate, with the relevant teams to develop an agreed management plan. Details on how local providers can access this process will be in place by November 2024, enabling clinicians to make best use of this support.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop an integrated diabetic-care model covering complex cases, multidisciplinary case management and mental-health support.

    Verbatim wording from the response

    “To address variation in service provision within different parts of the ICS, the ICB is working with local providers to develop a new, integrated model of diabetic care reflecting the needs of all diabetic patients. This includes the management of complex cases involving multi-disciplinary case management, including mental health support.”

    Source location

    Response from Hertfordshire and West Essex ICB
    Page 2 · response
    Published 30 July 2024

    Open published response

  3. Norfolk

    AI-generated summary

    Janice HOPPER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent blood-sugar monitoring instructions across documents

    Wider context from the report

    “5. Mrs Hopper was diagnosed with Diabetes. The Care Plan provided for Mrs Hopper's blood sugar levels to be checked twice weekly. This information differed from information contained in other documents. Mrs Hopper's blood sugar levels were not checked until the day she presented as unwell and was admitted to hospital, some fourteen days after admission. ”

    Source location

    Janice HOPPER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to check blood sugar levels twice weekly

    Wider context from the report

    “5. Mrs Hopper was diagnosed with Diabetes. The Care Plan provided for Mrs Hopper's blood sugar levels to be checked twice weekly. This information differed from information contained in other documents. Mrs Hopper's blood sugar levels were not checked until the day she presented as unwell and was admitted to hospital, some fourteen days after admission. ”

    Source location

    Janice HOPPER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of recorded diabetes-specific dietary instructions

    Wider context from the report

    “6. The Care Plan provided for Mrs Hopper to be on a controlled diet due to her diagnosis of Diabetes. Evidence was heard this meant "low sugar" and staff were made aware of this orally. There was no record of any specific diet relating to Mrs Hopper or to a resident with a diagnosis of diabetes. ”

    Source location

    Janice HOPPER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain person-centred diabetes care plans covering hypo- and hyperglycaemia responses and residents’ dietary requirements.

    Verbatim wording from the response

    “Further to the inquest, all residents with a diagnosis of diabetes, whether it be tablet or diet control, are now having their blood sugars monitored via the GP practice and these residents are having their bloods taken every 3-6 months. All care plans are now person centred to the individual with how staff should respond to a resident who may be experiencing hypo/hyperglycaemic episodes, and they better reflect the residents dietary requirements. As part of the process of reviewing care plans for residents with diabetes, advice was obtained from the catering and hospitality lead, who also worked closely with a nutritionist on the menus for the care home, which included advice related to menus for residents with diabetes.”

    Source location

    Response from Runwood Homes
    Page 2 · response
    Published 1 December 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor blood glucose and obtain blood tests every three to six months for residents with diabetes through the GP practice.

    Verbatim wording from the response

    “Further to the inquest, all residents with a diagnosis of diabetes, whether it be tablet or diet control, are now having their blood sugars monitored via the GP practice and these residents are having their bloods taken every 3-6 months. All care plans are now person centred to the individual with how staff should respond to a resident who may be experiencing hypo/hyperglycaemic episodes, and they better reflect the residents dietary requirements. As part of the process of reviewing care plans for residents with diabetes, advice was obtained from the catering and hospitality lead, who also worked closely with a nutritionist on the menus for the care home, which included advice related to menus for residents with diabetes.”

    Source location

    Response from Runwood Homes
    Page 2 · response
    Published 1 December 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review diabetes menus with catering and nutrition staff at monthly nutritional meetings, minute the discussions and distribute the information to care and kitchen teams.

    Verbatim wording from the response

    “Further to the inquest, all residents with a diagnosis of diabetes, whether it be tablet or diet control, are now having their blood sugars monitored via the GP practice and these residents are having their bloods taken every 3-6 months. All care plans are now person centred to the individual with how staff should respond to a resident who may be experiencing hypo/hyperglycaemic episodes, and they better reflect the residents dietary requirements. As part of the process of reviewing care plans for residents with diabetes, advice was obtained from the catering and hospitality lead, who also worked closely with a nutritionist on the menus for the care home, which included advice related to menus for residents with diabetes.”

    Source location

    Response from Runwood Homes
    Page 2 · response
    Published 1 December 2022

    Open published response

  4. Rutland and North Leicestershire

    AI-generated summary

    Colleen Alice FLETCHER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Colleen Fletcher, who was insulin-dependent and cared for in a residential care home, experienced progressively rising blood glucose levels, collapsed into a diabetic coma and died on 29 January 2021. The report raises concerns about the availability of rapid-acting insulin for patients whose glucose levels were previously stable, and the potential delay before increased insulin could be administered or ambulance assistance considered necessary.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of standby rapid-acting insulin prescriptions for otherwise stable diabetic patients

    Wider context from the report

    “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. ”

    Source location

    Colleen Alice FLETCHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed Home First into the revised pathway to support administration of rapid-acting insulin within two hours of referral when clinically necessary.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Leicester, Leicestershire and Rutland
    Page 2 · response
    Published 10 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise insulin authorisation forms, require their use, and include frailty-based dosing guidance and recorded authorisation for ad hoc rapid-acting insulin.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Leicester, Leicestershire and Rutland
    Page 2 · response
    Published 10 October 2022

    Open published response

  5. Berkshire

    AI-generated summary

    Colm MCCABE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Colm McCabe, aged 79, was admitted to hospital with hyperglycaemia after his blood sugar levels were not monitored and insulin administration was not clarified at the care home. He was transferred to hospital on 22 March 2021 and died there on 24 March 2021; the inquest concluded that natural causes were contributed to by neglect. Concerns included staff recruitment, training and appraisal, ineffective auditing, failures to clarify and monitor diabetes care, and the candour and completeness of investigations by the care home.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify and clarify blood sugar monitoring issues

    Wider context from the report

    “2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this. We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors, including the fact that a 72 hour review was not carried out, that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses. ”

    Source location

    Colm MCCABE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester City

    AI-generated summary

    Jude Daryl Lloyd · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of comprehensive diabetes monitoring and management risk review and care planning before discharge

    Wider context from the report

    “a. No thorough comprehensive risk review and care plan was formulated in relation to his Diabetes monitoring and management prior to his discharge from the inpatient unit. This was not recognised before he left the ward and it was not discovered by the CMHT when they took over his care. ”

    Source location

    Jude Daryl Lloyd · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider diabetes-related causes of reported side effects and seek appropriate clinical advice

    Wider context from the report

    “f. Despite complaining of side effects, there was no apparent awareness of or consideration given to the risk and likelihood that these may be associated with his diabetes. No appropriate clinical advice was sought. ”

    Source location

    Jude Daryl Lloyd · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.

    Verbatim wording from the response

    “Going forward the Trust physical health care group will reinstate a Diabetes workstream to continue to improve the management of people with diabetes across the Trust. We will ensure that the Diabetes workstream have oversight of compliance with training about diabetes management and are involved in the management and risk analysis incidents around diabetes care. We intend to make the care of someone with diabetes as one of our main quality improvement care projects in the organisation that will be led by the physical health care group who will act as the lead for this. This will involve further enhancing the connections and communication with primary care and will involve the new primary healthcare practitioners, which are new joint posts working across the new primary care networks and GMMH.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 13 October 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Address coordination of diabetes management at discharge through the diabetes steering group.

    Verbatim wording from the response

    “The HbA1c is a measurement of control of blood glucose (glycaemic control) over the weeks prior to the test being taken so the HbA1c of 135 suggested extremely poor glycaemic control in the community whilst Mr Lloyd was under the care of his GP prior to admission. We agree that sadly, the plan to ask the GP to follow this up on discharge was unlikely to have led to any improvement in glycaemic control and was not a robust plan to manage this. We will address discharge diabetes management coordination via the diabetes steering group.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 13 October 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide recurring eLearning on physical-health and diabetes management to relevant clinical staff, with knowledge testing.

    Verbatim wording from the response

    “A further recommendation was to raise awareness and education on monitoring for signs of diabetic ketoacidosis for CMHT staff. To address this an eLearning training package is in place in respect of supporting and monitoring physical health of a patient under mental health services. All”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 1 · response
    Published 13 October 2021

    Open published response

  7. Wiltshire and Swindon

    AI-generated summary

    Thomas Wedrychowski · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Wedrychowski had paranoid schizophrenia and had been prescribed antipsychotic medication for a number of years. Expert evidence indicated that the medication caused diabetes and contributed to morbid obesity; the medical cause of death was recorded as diabetic ketoacidosis and medication-induced diabetes mellitus. Concerns included whether higher-risk patients should receive more frequent diabetes monitoring and whether physical healthcare findings were adequately shared between primary and secondary care providers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide more frequent diabetes monitoring for individuals at higher risk

    Wider context from the report

    “At both primary and secondary health levels it appeared to have been the view that following initial titration and a period of regular checks, annual monitoring for signs of the development of diabetes should be carried out annually as recommended in NICE guideline CG178. However, expert evidence at the inquest suggested that in cases of individuals with a higher risk of developing diabetes, more regular checks were called for. Further there was evidence to the effect that the results of relevant physical healthcare checks had not been shared between primary and secondary healthcare providers. Thus: (1) I draw to the attention of the National Institute for Health and Care Excellence their guidance CG178 and specifically clause 1.3.6.4 thereof and ask them to consider whether to the directive for an annual test of inter alia HbA1c, there might be added the words: “or more frequently in those who have a higher baseline risk for the development of diabetes”. (2) I draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with reference to their planned review of their document entitled “Medicines Guideline: Monitoring psychotropic medication” my first paragraph addressed to the National Institute for Health and Care Excellence and ask them to consider adding similar wording to their recommendations with regard to annual review appearing at page 4 of the present document. Secondly, I ask the Trust to consider adding advice in the document to the effect that when a patient is prescribed anti-psychotic medication contact be made with the patient’s GP practice (a) informing them of this fact (b) requesting communication thereafter of any physical health findings that might indicate serious side-effects or potential side-effects of the drugs and (c) communicating any relevant physical health findings to the GP practice as well as mental health findings. ”

    Source location

    Thomas Wedrychowski · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. East Sussex

    AI-generated summary

    Martin Leslie Haines · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Martin Leslie Haines was detained at Lewes Prison and was found dead in his cell on 18 March 2018. He had Type II Diabetes and warning signs of cerebrovascular disease, but the appropriate diagnostic tests were not carried out; alcohol, Venlafaxine and Amitriptyline were later found in his system and considered by the pathologist to have contributed to his death. The principal concerns included inadequate diabetes and cardiovascular monitoring, healthcare falling below community standards, the ability to brew or distil alcohol in prison, a lack of protocols for responding to an unresponsive body, and insufficient communication between healthcare providers and the prison service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to carry out diagnostic testing and monitoring for diabetes

    Wider context from the report

    “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease. ”

    Source location

    Martin Leslie Haines · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.

    Verbatim wording from the response

    “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Haines and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).”

    Source location

    2019-0486-Response-by-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 16 August 2019

    Open published response

  9. Nottinghamshire

    AI-generated summary

    Joan Osborne · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joan Osborne, who had diabetes and advanced dementia, died on 25 August 2017 after repeated difficulties obtaining her blood glucose levels and administering her insulin. The concerns included failures by nursing home staff to seek medical assistance or escalate her missed insulin, inadequate records, failure to recognise her deteriorating condition, and inaccurate blood glucose measurement and treatment on 22 August 2017.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to seek Dementia Outreach Team assistance for deteriorating blood glucose and insulin compliance

    Wider context from the report

    “(1) The nursing home staff did not seek assistance from the Dementia Outreach Team when Mrs Osborne’s compliance with her blood glucose levels and insulin prescription deteriorated at the end of 2016 onwards. ”

    Source location

    Joan Osborne · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to make staff available for pre-arranged Diabetes Nurse appointments

    Wider context from the report

    “(2) The nursing home did not make any members of staff available for the pre-arranged appointment with the Diabetes Nurse on 28.11.2017 resulting in a missed opportunity to seek assistance with Mrs Osborne’s compliance. ”

    Source location

    Joan Osborne · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish regular Dementia Outreach Team referrals, communication and management monitoring for residents requiring support.

    Verbatim wording from the response

    “(1) Since the appointment of the new Home Manager, ████████, and the new Deputy Home Manager, ████████, at ‘Adbolton Hall’, the nursing home staff now seek regular assistance from the Dementia Outreach Team. This assistance is sought as and when required, however on average takes place a minimum of once a month, ensuring regular communication with this Team. This can be evidenced upon review of the Professional Visits Book and Multi-disciplinary Team Communication Sheets where applicable in residents' care plans.”

    Source location

    2018-0091-Response-by-Adbolton-Hall-Ltd
    Page 3 · response
    Published 16 June 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure nursing and management staff attend all pre-arranged multidisciplinary team appointments.

    Verbatim wording from the response

    “(2) The nursing home ensures always that members of staff are made available for all pre-arranged appointments with all Multi-disciplinary Team staff members which are diarised in the Home Diary situated within the office. The home ensures that the Nurse-in-charge, Care Co-ordinators or the Home Manager are available for these appointments. There have also been occasions when Multi-disciplinary Team professionals have visited ‘Adbolton Hall’ unannounced, and staff have always been made available to see them.”

    Source location

    2018-0091-Response-by-Adbolton-Hall-Ltd
    Page 3 · response
    Published 16 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Diabetes care is considered adequately assessed and provided because relevant authorities were satisfied the home’s complex-needs admissions were safe.

    Verbatim wording from the response

    “their pre-admission assessments were sent to ████████, Management Officer for the Quality and Market Management Team within Nottinghamshire County Council, and ████████, Care Home Quality Lead Nottingham North and East, Nottingham West and Rushcliffe Clinical Commissioning Group, to ensure that they were confident that the home could meet each individual’s needs. On 26 March 2018, ████████ advised the home that they were not required to continue to send these to them, as they were satisfied that all the home’s admissions, including those with individuals with complex needs, were safe. We are confident therefore that diabetes care is adequately assessed and provided for.”

    Source location

    2018-0091-Response-by-Adbolton-Hall-Ltd
    Page 4 · response
    Published 16 June 2018

    Open published response

  10. Blackpool and the Fylde

    AI-generated summary

    Barry THOMPSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clear instructions and staff knowledge for monitoring diabetic patients with sepsis

    Wider context from the report

    “(2) Managing a diabetic patient. Instructions were not given as to how frequently Mr Thompson’s blood sugar and ketones should be monitored. The evidence was that this should be every hour. After 16.15 hours there was one measurement of blood sugar and a later recording on the acute medical unit (untimed) and no measurement of ketones. It is of concern that staff were not clear how frequently to monitor a diabetic patient, nor are with a concomitant condition i.e. sepsis, or where to locate a Ketone box for testing .Diabetes is a very common medical problem which hospital staff encounter frequently. Another inquest approximately 18 months ago was heard at Blackpool concerning the management of a diabetic patient where, although the facts and personnel differed the same conclusion was recorded. In that case the author of the Serious Incident Review concluded there was a lack of “joined up thinking”. ”

    Source location

    Barry THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026