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Investigation and inquest
On 31st January 2014 I commenced an investigation into the death of Pamela Pattison dob 13th May 1944. The investigation concluded on the 17th March 2015 and the conclusion was one of a Narrative Conclusion. The medical cause of death was 1a Aspiration Pneumonia following insertion of naso-gastric tube for nausea and vomiting consequent upon unstable diabetic control. 1b. Brittle diabetes with diabetic nephropathy and diabetic neuropathy. Fractured neck of femur.
Circumstances of the death
On the 6th January 2014 she fell at her home address and broke her hip. She was admitted to Stepping Hill Hospital and was operated on for her fractured femur. She had numerous co-morbidities including Type 1 Diabetes. On the 17th January her insulin doses were intentionally omitted due to mistaken assessment by one of the medical staff. She was cared for by relatively junior medical and nursing staff when in fact she ought to have been cared for in the HDU. As a result her diabetic care was sub-optimal and various failings led to her being nauseous and tending to vomit, leading to her developing aspiration pneumonia.
Coroner’s concerns
1. From the evidence it was apparent that nurse training on wards M4 and A11 was deficient and their understanding of the importance and danger of Type 1 Diabetes seemed to be limited at best. The nurses were unable to say why they had not escalated her care on a number of occasions.
2. ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin'. The consultant expressed the 'hope' that they would know this, but the evidence suggested the contrary.
3. It was evident that the nursing staff on, for example, the surgical wards, did not have any specialist outreach nurse advice on such things as diabetes.
4. There was an obvious need for additional consultant cover for Diabetes. I was told that funding has been put in place to cover this, but as yet no one has been appointed to fulfil this vital role.
5. The specialist outreach Nurse Practitioner for diabetes was booked off sick for one month, and no 'cover' was in place to cover his absence.
6. There was either a lack of equipment or a lack of understanding by the staff as to what equipment was needed by them. The staff indicated that they were unable to find 'ketone dipsticks', for diabetic urine sampling. I was told that in fact these are unnecessary in that ketone blood tests are now routine. Similarly I was told they could not find any or sufficient cardiac monitors on the ward. Further evidence revealed there are in excess of 240 such monitors in the hospital but the relevant staff seemed unaware of this. They were also unaware that they could have used the ward based defibrillator for the same purpose.
7. There was a considerable delay of approximately 12 hours in moving her to ward A3 after she had been deemed the appropriate place for her to be. No reason for this delay was offered.
8. It was conceded by the ‘Head of Risk’ for the Trust, that there was a general under resourcing within the Trust for the care of patients with Diabetes.
Information checked against the published report and official responses