5 Feb 2025 Mr Leslie Hurwood · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2 Failure of insulin-administration training to reach all nurses View source Failure to administer insulin before meals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Leslie Hurwood · 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
Mr Leslie Hurwood died on 13 January 2023 at Kettering General Hospital, having had a history of Type I diabetes and other health conditions, and a recent diagnosis of dementia. During a December 2022 admission after a fall, he experienced multiple episodes of hypoglycaemia. The report raises concerns that nurses at Northampton General Hospital administered insulin after meals rather than before them, and that this practice continued to occur occasionally despite advice 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. The report was sent to Northampton General Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of insulin-administration training to reach all nurses
Wider context from the report “In December 2022 Mr Hurwood was an in-patient at Northampton General Hospital. This followed a fall at home. During this admission he suffered multiple episodes of hypoglycaemia. Mr Hurwood’s insulin medication was to be provided by nurses within the hospital.
I have heard evidence from a Diabetes Specialist Nurse at the Diabetes Centre at Northampton General Hospital that on 12 December 2022 Mr Hurwood was referred by ward staff for a diabetes review. The Diabetes Specialist Nurse explained in evidence that she observed that nurses (plural) were administering Mr Hurwood’s insulin after meals. She advised the nurses that Mr Hurwood’s insulin should be provided before his meals.
In evidence, the Diabetes Specialist Nurse told me:
a. Insulin should be administered prior eating.
b. Its effectiveness is reduced if not administered before eating.
c. This was not the only time that she was aware that nurses at Northampton General Hospital were (incorrectly) administering insulin to patients after they had eaten their meals.
d. This continues to happen “occasionally”: the most recent episode which she had directly encountered occurred in the last 2 to 3 months.
e. Whilst the Diabetes Centre members have had discussions with nurses and training does occur “the message does get through for some people”. The implication – which she agreed was the correct implication – was that the “message” did not get through to other nurses.
A former Ward Sister at Northampton General Hospital has also given evidence at the inquest. She agreed that staff must get insulin administration correct. She thought the incorrect administration of insulin after a meal “probably does happen”. She accepted that there was “no excuse” for this, but pointed to the possible contributory effect of a lack of staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northampton General Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer insulin before meals
Wider context from the report “In December 2022 Mr Hurwood was an in-patient at Northampton General Hospital. This followed a fall at home. During this admission he suffered multiple episodes of hypoglycaemia. Mr Hurwood’s insulin medication was to be provided by nurses within the hospital.
I have heard evidence from a Diabetes Specialist Nurse at the Diabetes Centre at Northampton General Hospital that on 12 December 2022 Mr Hurwood was referred by ward staff for a diabetes review. The Diabetes Specialist Nurse explained in evidence that she observed that nurses (plural) were administering Mr Hurwood’s insulin after meals . She advised the nurses that Mr Hurwood’s insulin should be provided before his meals.
In evidence, the Diabetes Specialist Nurse told me:
a. Insulin should be administered prior eating.
b. Its effectiveness is reduced if not administered before eating.
c. This was not the only time that she was aware that nurses at Northampton General Hospital were (incorrectly) administering insulin to patients after they had eaten their meals.
d. This continues to happen “occasionally” : the most recent episode which she had directly encountered occurred in the last 2 to 3 months.
e. Whilst the Diabetes Centre members have had discussions with nurses and training does occur “the message does get through for some people”. The implication – which she agreed was the correct implication – was that the “message” did not get through to other nurses.
A former Ward Sister at Northampton General Hospital has also given evidence at the inquest. She agreed that staff must get insulin administration correct. She thought the incorrect administration of insulin after a meal “probably does happen” . She accepted that there was “no excuse” for this, but pointed to the possible contributory effect of a lack of staff.
” Open source report
12 Jan 2024 Iona Grace Buckingham · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Unavailability of immediate paediatric chest ultrasound assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Iona Grace Buckingham · 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
Iona Grace Buckingham was admitted to Northampton General Hospital with bronchiolitis and later developed pneumonia, pleural effusion and worsening respiratory distress. She died on 4 December 2022 during an accidental extubation and cardiac arrest, despite attempts at resuscitation. The principal concern was that a very unwell child requiring a chest ultrasound may face a substantial delay because paediatric radiology services were not routinely available outside limited hours, potentially for up to 48 hours over a weekend.
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. The report was sent to Northampton General Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of immediate paediatric chest ultrasound assessment
Wider context from the report “The recommendation made by the investigation panel was that children with pneumonia who are not improving after forty-eight hours of treatment or deteriorate at a later point should get “an immediate x-ray and chest ultrasound”. However, the evidence I heard suggests this is not possible .
I heard from the Clinical Director that as a district general hospital, Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays when such a specialist is either on duty or on-call. I heard evidence that in Iona’s case, a Consultant in ITU and Anaesthesia was able to perform an ultrasound scan at around 2pm on 4th December 2022 however this is not a facility that would routinely be available to the Trust and was not, in any event, part of that clinician’s core duties.
I am concerned that a very unwell child who may require a chest ultrasound may not receive one ‘immediately’ and in fact may have to wait for a considerable period of time . For example, if the need arose over a weekend, that child may not receive an ultrasound scan for up to 48 hours .
” 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 Train a paediatric consultant in point-of-care ultrasound.
Verbatim wording from the response “Currently the trust has one whole time equivalent radiologist that can undertake paediatric radiology. One of the paediatric consultants is undertaking training in Point of Care Ultrasound (POCUS) and there is a charitable funds request for the purchase of a POCUS ultrasound machine for the department. There is a further paediatric consultant who can already undertake chest ultrasound scanning.” Source location Response from Northampton General Hospital NHS Trust
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 collaborative paediatric radiology pathways and provision across Northamptonshire and Leicester providers.
Verbatim wording from the response “The radiology department are currently reviewing the possibility of joint recruitment of a radiologist with a paediatric sub specialism working between Northampton General Hospital NHS Trust (NGH) and University Hospitals of Leicester NHS Trust (UHL). There are currently discussions with both UHL and University Hospitals of Northamptonshire NHS Group (incorporating NGH and Kettering General Hospital NHS Foundation Trust) to review how the providers within the system can work more collaboratively, reviewing current pathways and provision.” Source location Response from Northampton General Hospital NHS Trust
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 Request charitable funding to purchase a point-of-care ultrasound machine.
Verbatim wording from the response “Currently the trust has one whole time equivalent radiologist that can undertake paediatric radiology. One of the paediatric consultants is undertaking training in Point of Care Ultrasound (POCUS) and there is a charitable funds request for the purchase of a POCUS ultrasound machine for the department. There is a further paediatric consultant who can already undertake chest ultrasound scanning.” Source location Response from Northampton General Hospital NHS Trust
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 joint recruitment of a paediatric-subspecialist radiologist with University Hospitals of Leicester NHS Trust.
Verbatim wording from the response “The radiology department are currently reviewing the possibility of joint recruitment of a radiologist with a paediatric sub specialism working between Northampton General Hospital NHS Trust (NGH) and University Hospitals of Leicester NHS Trust (UHL). There are currently discussions with both UHL and University Hospitals of Northamptonshire NHS Group (incorporating NGH and Kettering General Hospital NHS Foundation Trust) to review how the providers within the system can work more collaboratively, reviewing current pathways and provision.” Source location Response from Northampton General Hospital NHS Trust
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 action on paediatric radiology provision will await responses from the Integrated Care Board and NHS England because the issue extends beyond the Trust.
Verbatim wording from the response “The issue that has been raised by the coroner in relation to the provision of paediatric radiology is a much wider issue than NGH itself. A Regulation 28 Prevention of Future Deaths has also been issued to the Integrated Care Board (ICB) as well as NHS England. The trust will await these responses to develop future further actions if required.” Source location Response from Northampton General Hospital NHS Trust
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 Training on-call radiologists in basic paediatric thoracic ultrasound and providing 24/7 trained paediatric radiology are unachievable because of staffing, competence and national workforce constraints.
Verbatim wording from the response “There has been a suggestion that the current on call registrar / consultant radiologists are trained in basic paediatric thoracic ultrasound. However, Radiology have expressed a concern that this would not be achievable with current on call and staffing numbers and would potentially underestimate the role and specialism of paediatric radiologists.” Source location Response from Northampton General Hospital NHS Trust
Open published response
25 Aug 2023 Miss C · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Inadequate policy for out-of-hours availability of Resuscitation Officers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Miss C · 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
Miss C died at Northampton General Hospital on 5 October 2021. The primary underlying causes were recent weight loss with nutritional deficiencies and interstitial pneumonia. During her deterioration, a doctor’s review was delayed, representing a missed opportunity for enhanced supportive care and an earlier peri-arrest call. Concerns also included the out-of-hours availability of Resuscitation Officers and aspects of the cardiac-arrest management, including inconsistent records of dextrose administration.
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. The report was sent to Northampton General Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy for out-of-hours availability of Resuscitation Officers
Wider context from the report “Resuscitation Council UK and NGH NHS Trust should consider a review of their policy in relation to the out of hours availability of Resuscitation Officers .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations