James Owen DELANEY · Prevention of Future Deaths report

On 07/08/2018 I commenced an investigation into the death of James Owen DELANEY aged 37. The investigation concluded at the end of the inquest on 19/06/2019. The conclusion of the inquest was: Natural causes aggravated by neglect

1a Diabetic Ketoacidosis
1b
1c
II

Mr Delaney was a resident at Sapphire House Care Home. He was an insulin controlled Diabetic and was not always compliant with his medication. The consequence of not taking his insulin was recognised as possibly life threatening. Care Home protocols included medical advice be obtained on a service user not taking medication for twenty-four hours. On 25 and 26 July 2018 Mr Delaney refused his two doses of insulin, which was noted in the records. On 27 July Mr Delaney became unwell with sickness and diarrhoea and again was noted not to have taken his medication. Mr Delaney was placed on 15 minute observations. Overnight Mr Delaney was found on the floor where a bed was made for him. On the morning of 28 July 2018, the final recorded observation of Mr Delaney was at 10 am when he remained unwell. At the next observation Mr Delaney was found unresponsive. Emergency services were called at 10.43 am. Mr Delaney was pronounced dead at 11.42 am.

1. There are several general Policies and Procedures in place and individual documents relating to service users. Whilst staff are now given ring-fenced time to read and understand those documents on entering the Home, the evidence is that time is not set aside to refresh themselves at regular intervals with regard to this information;
2. The Medication Policy covering all medication, all service users at all Homes within the Crystal Care umbrella organisation, provides a GP should be called if medication is not taken for 24 hours. At Sapphire House staff have been sent an email requiring them to call a GP should a service user refuse one dose of medication. This is not a standard procedure across all Homes and could lead to confusion, particularly should staff transfer between Homes and on new staff joining who may not have access to the email.