PATRICIA LILLIAN CHAPMAN · Prevention of Future Deaths report

On 30th July 2013 I commenced an investigation into the death of PATRICIA LILLIAN CHAPMAN, Aged 77 years. The investigation concluded at the end of the inquest on 21st April 2015 The conclusion of the inquest was “The avoidable consequence of an avoidable hypoglycaemic episode”, with a cause of death Hypoglycaemia.

The deceased was a patient at Sedgefield Community Hospital. In the afternoon of the 8th of July 2013 she had a severe Hypoglycaemic attack but following an injection, apparently recovered. In the early morning of the next day she died from another Hypoglycaemic attack. The inquest has revealed a number of shortcomings with regard to the deceased's care. Many changes in practice policy and procedure have been implemented since her death.

(1) The revised training and flow chart does not include any reference to staff in a community hospital being able to obtain emergency advise from an expert in the emergency department of one of the Trust’s acute hospitals (or from an expert in another department of the said hospitals if appropriate) to assist in giving immediate medical cover whilst, for example, other steps are being taken or whilst an ambulance is on route after having been summoned. It may well be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying to ensure a patient's safety and this is not included in the revised Trust policies. This is something that should be given consideration to.