Colm MCCABE · Prevention of Future Deaths report

On 12th May 2021 I commenced an investigation into the death of Colm MCCABE aged 79. The investigation concluded at the end of the inquest on 11 January 2022. The conclusion of the inquest was natural causes contributed to by neglect.

Mr McCabe was a 79 year old gentleman who had been diagnosed with diabetes in 1992, and dementia in 2012. He was admitted to the Royal Berkshire Hospital on 3rd March 2021 and discharged to a "discharge to assess" bed at Berkshire Care Home in Wokingham, Berkshire on 9th March last year.

There was some confusion about insulin administration at the time of his discharge from hospital, but no attempt was made by the home to clarify this.

His blood sugar levels were not monitored at the care home between the afternoon of the 15th March and the morning of 22nd March 2021 despite a result of 16.5 mmol/L on the morning of 15th March. He was eating and drinking very little. The blood sugar monitoring plan was based on staff’s experience of an entirely different patient, who was not insulin dependent. No medical review of Mr McCabe was sought before 22nd March, by which time he was borderline comatose, dehydrated and hyperglycaemic, with a blood sugar level of 27.7 mmol/L. He was transferred to the Royal Berkshire Hospital, Reading, Berkshire, on 22nd March, but died there on 24th March 2021.

His cause of death was

1a Pneumonia
1b Hyperosmolar-hyperglycaemic state
1c Type II Diabetes Mellitus
Part II Dementia

The evidence was clear that there was a link between the failure to monitor blood sugar levels and administer insulin accordingly on the one hand, and his admission with hyperglycaemia and subsequent death on the other.

In considering my responsibilities under Regulation 28, I was concerned about the level of candour and the depth of investigation by Four Seasons and Berkshire Care Home in relation to this matter.

1. A number of the policies referred to at the inquest were in fact already in place at the time of this death. Many of these were not followed. I remain concerned about recruitment of staff, training of staff, and appraisals of staff.

2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this. We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors, including the fact that a 72 hour review was not carried out, that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses.

3. I heard evidence about investigations carried out by the home, and the fact that initial responses to enquiries from the CQC suggested that the management had been appropriate. I am concerned to know to what extent care homes run by Four Seasons carry out full and candid investigations and produce reports accordingly, and what training is given to managers in this respect?