Recurring concern

Failure to reliably measure and monitor blood glucose levels

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First reported 25 Jul 2014•Latest report 13 Jan 2026

Definition

What this concern includes

Includes failures of controls specifically dedicated to measuring, monitoring, reviewing or following up blood glucose levels, including inaccurate measurement, omitted or untimely testing, inadequate trend review and failure to establish whether testing was completed after refusal, across relevant clinical and care settings.

Not included

Excludes broader diabetes-care failures where blood-glucose measurement or monitoring is not the identified unsafe condition.
Excludes failures limited to prescribing, administering or supplying insulin or other treatment after reliable glucose monitoring has occurred.
Excludes generic equipment, staffing, training, documentation or escalation deficiencies unless they directly impair the blood-glucose measurement or monitoring process.
Excludes glucose-tolerance testing and other diagnostic testing where the concern is pregnancy-status identification, test-request information or interpretation rather than monitoring blood glucose levels.

Reports: 13
Individual concerns: 18
Date range: 2014–2026
Stated actions: 19

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

Adbolton Hall1

Bank Close House1

Bilbrook Medical Centre1

Blackpool Teaching Hospitals NHS Foundation Trust1

Care Quality Commission1

Four Seasons Health Care Group1

Maidstone and Tunbridge Wells NHS Trust1

Medicines and Healthcare products Regulatory Agency1

National Institute for Health and Care Excellence1

Northern Care Alliance NHS Foundation Trust1

Royal Free London NHS Foundation Trust1

Runwood Homes Limited1

South London and Maudsley NHS Foundation Trust1

Springfield House Nursing Home1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

22 Apr2015
Black Country
Concerns raised1
1. Failure to perform regular blood glucose testing for patients with diabetes risk factors
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Eliza Rebecca Bowen · 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

Eliza Bowen, a resident of Springfield House Care Home with complex medical needs, became suddenly unwell on 15 November 2014 and died after developing markedly raised blood glucose, acute kidney injury and metabolic imbalances. The inquest concluded that she died from hyperosmolar non-ketotic coma, a natural cause of death. The principal concerns were that regular blood glucose testing might have identified diabetes sooner and that guidance on diabetes screening and management for patients with relevant risk factors should be available to medical staff.

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 perform regular blood glucose testing for patients with diabetes risk factors
Wider context from the report
“1. A simple blood glucose test done on a regular basis may have identified the diabetes sooner and the condition managed. 2. Although the patient wasn’t identified as a diabetic she presented with some of the key associated risk factors including BMI greater than 30 and immobility due to her medical condition. ”
Source location
Eliza Rebecca Bowen · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 Sep2014
Inner North London
Concerns raised2
1. Failure to promptly re-check blood sugar after significant hyperglycaemia
2. Lack of a well-understood protocol for rechecking and escalating refused blood glucose checks
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas Charles TAYLOR · 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 Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

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 promptly re-check blood sugar after significant hyperglycaemia
Wider context from the report
“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. ”
Source location
Thomas Charles TAYLOR · 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 a well-understood protocol for rechecking and escalating refused blood glucose checks
Wider context from the report
“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. ”
Source location
Thomas Charles TAYLOR · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Jul2014
Sunderland
Concerns raised2
1. Failure to provide timely blood glucose testing for newborns
2. Lack of finalized and current guidance on newborn blood glucose testing
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  The imminent NICE guidance review cannot be expedited.
  Stated by Department of Health and Social CareUnable to act
1. Position
  Further questions about the guidance review should be directed to NICE, an independent body.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Nathan James Healer · 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

Nathan James Healer was born on 03/02/2014 and died on 05/02/2014 after developing signs including low temperature, poor feeding and jittering arms. His first blood glucose measurement, taken almost five hours after birth, was 0.2 mmol/L. The principal concern was that the severity of his condition was not appreciated and he was not given a more timely blood glucose test, in the context of existing clinical guidance.

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 timely blood glucose testing for newborns
Wider context from the report
“I was made aware of :- a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours; b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014; c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours). Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test I heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised. If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production. If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event. ”
Source location
Nathan James Healer · Prevention of Future Deaths report
Page 1 · 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 finalized and current guidance on newborn blood glucose testing
Wider context from the report
“I was made aware of :- a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours; b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014; c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours). Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test I heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised. If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production. If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event. ”
Source location
Nathan James Healer · 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
The imminent NICE guidance review cannot be expedited.

Verbatim wording from the response
“Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However, as NICE is an independent body, I advise you contact it directly with any further questions you may have about the review of this guidance.”

Source location
2014-0343-Response-by-Department-of-Health
Page 2 · response
Published 25 July 2014
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
Further questions about the guidance review should be directed to NICE, an independent body.

Verbatim wording from the response
“Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However, as NICE is an independent body, I advise you contact it directly with any further questions you may have about the review of this guidance.”

Source location
2014-0343-Response-by-Department-of-Health
Page 2 · response
Published 25 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to perform regular blood glucose testing for patients with diabetes risk factors

Concerns raised2

Failure to promptly re-check blood sugar after significant hyperglycaemia

Lack of a well-understood protocol for rechecking and escalating refused blood glucose checks

Concerns raised2

Failure to provide timely blood glucose testing for newborns

Lack of finalized and current guidance on newborn blood glucose testing

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Respondent positions 2