Recurring concern

Unsafe recognition and management of hypoglycaemia

First to latest report 27 Sep 2013 — 30 Jul 2025

Reports that mention this concern: 4
Times this concern has been raised: 4
Stated actions linked to this concern: 3

What this concern includes

Includes failures of controls specifically dedicated to hypoglycaemia recognition and management, including staff education and competency assessment, monitoring, escalation, transfer, investigation, treatment and follow-up.

What is not included

Excludes generic training, staffing or clinical-management deficiencies unless they are explicitly tied to hypoglycaemia.
Excludes failures concerning other metabolic or electrolyte abnormalities unless the report directly identifies hypoglycaemia as the shared condition.
Excludes general deterioration, transfer or treatment failures where hypoglycaemia is not the specific hazard being recognised or managed.

Trends

Reports over time

Reports mentioning this concern, 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.

Bristol NHS Foundation Trust1

Consultant orthopaedic surgeon1

NHS Cornwall and the Isles of Scilly Integrated Care Board1

NHS England1

Nuffield Health1

Nuffield Health Brighton Hospital1

Royal Cornwall Hospital1

York and Scarborough Teaching Hospitals NHS Foundation Trust1

Reports and published responses 4 reports

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

30 Jul2025
North Yorkshire and York
Concerns raised1
1. Delays in treating hypoglycaemia
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions 2
1. York and Scarborough Teaching Hospitals NHS Foundation Trust
  Automatically transfer point-of-care blood glucose results into the electronic patient record and Emergency Department whiteboard.
2. York and Scarborough Teaching Hospitals NHS Foundation Trust
  Reorder blood-gas printout results so blood glucose appears higher and low readings are more readily identified.
AI-generated summary

Joanne Louise STONES · 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

Joanne Louise Stones, who had Anti-Phospholipid Syndrome and Addison’s Disease, was admitted with abdominal pain and diagnosed with acute cholecystitis with gallstones. Her condition deteriorated and she died in intensive care on 17 September 2023. Concerns included delays in prioritisation, treatment with fluids and antibiotics, recognition of her Addison’s Disease, and consideration of her underlying conditions in her treatment plan.

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
Delays in treating hypoglycaemia
Wider context from the report
“(2) There was delay in Joanne receiving fluids, which led to hypoglycaemia which was then not treated promptly. ”
Source location
Joanne Louise STONES · 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
Automatically transfer point-of-care blood glucose results into the electronic patient record and Emergency Department whiteboard.

Verbatim wording from the response
“It was identified in the Serious Incident Investigation report that the failure to identify Ms Stones’ hypoglycaemia was a significant failing when she presented acutely on her final attendance. The Trust has already implemented two actions designed to reduce the risk of a low blood sugar being missed/not actioned in future patients. These actions are to:”

Source location
Response from York and Scarborough Teaching Hospitals
Page 3 · response
Published 31 July 2025
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
Reorder blood-gas printout results so blood glucose appears higher and low readings are more readily identified.

Verbatim wording from the response
“It was identified in the Serious Incident Investigation report that the failure to identify Ms Stones’ hypoglycaemia was a significant failing when she presented acutely on her final attendance. The Trust has already implemented two actions designed to reduce the risk of a low blood sugar being missed/not actioned in future patients. These actions are to:”

Source location
Response from York and Scarborough Teaching Hospitals
Page 3 · response
Published 31 July 2025
Open published response
10 May2021
Brighton and Hove
Concerns raised1
1. Failure to manage hypoglycaemia
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr. John Charles LOTT · 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

John Lott underwent surgery to form a defunctioning ileostomy and subsequently became seriously unwell, including inadequately treated hypoglycaemia, myocardial ischaemia and infarction. He died on 8 November 2020 after two occasions when transfer from the private hospital to an NHS hospital with appropriate critical care facilities was considered necessary but did not occur. Concerns included missed transfer opportunities, inadequate management of hypoglycaemia, and a lack of contact with the on-call anaesthetist when the consultant was unavailable.

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 manage hypoglycaemia
Wider context from the report
“(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield. (2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred. ”
Source location
Mr. John Charles LOTT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 May2016
Cornwall and Isles of Scilly
Concerns raised1
1. Use of a single birth-weight threshold in hypoglycaemic guidance
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Charlie Mark Jermyn · 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

Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

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
Use of a single birth-weight threshold in hypoglycaemic guidance
Wider context from the report
“6. The Expert Midwife advised that the use of a single birth weight in the Trusts hypoglycaemic guidance (at risk at 2.5 kg) was not best practice and suggested the use of three weights: pre term, term, and late weight. ”
Source location
Charlie Mark Jermyn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Sep2013
Avon
Concerns raised1
1. Lack of competency-assessed education on hypoglycaemia for doctors and midwives
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Bristol NHS Foundation Trust
Stated actions 1
1. Bristol NHS Foundation Trust
  Update, govern, disseminate and provide required training on clinical guidelines for newborn infants at risk of hypoglycaemia.
AI-generated summary

Jared William McDowall · 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

Jared William McDowall was born on 15 January 2012 and died unexpectedly at the hospital on 17 January 2012, aged 48 hours. The inquest concluded that he died from natural causes and had medical conditions that had not been diagnosed. Concerns included the weight thresholds used to determine monitoring, the need for guidance based on gestation and sex, improved presentation of risk information, joint working, and education on hypoglycaemia and recognising an unwell baby.

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 competency-assessed education on hypoglycaemia for doctors and midwives
Wider context from the report
“During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff. In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency. ”
Source location
Jared William McDowall · Prevention of Future Deaths report
Page 1 · 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
Update, govern, disseminate and provide required training on clinical guidelines for newborn infants at risk of hypoglycaemia.

Verbatim wording from the response
“| JWM | Update clinical guidelines for at risk new-born infants, secure sign off through appropriate governance channels and disseminate with training as required. | ████████ | 31st January 2014”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response