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Investigation and inquest
On 28 January 2021, I commenced an investigation into the death of Michael Jaggs, aged 72 years. The investigation concluded at the end of the inquest on 21 September 2021. I made a determination at inquest as follows.
Michael Jaggs was admitted to hospital on 15 January 2021 and treated for hyperkalaemia. He developed hypoglycaemia as a complication of this treatment. The agency nurse looking after him failed to escalate his deterioration to doctors, and he died from the hypoglycaemia. He was suffering from several chronic co-morbidities, but his death occurred when it did as a direct consequence of the failure to escalate his condition for medical attention.
Circumstances of the death
Mr Jaggs was looked after by a nurse from your agency. By 3am on 16 January 2021, he had a blood sugar level of 1.9 and the agency nurse did notify the nurse in charge, who instructed her to bleep a doctor to prescribe dextrose.
The agency nurse told me that either she did not hear that instruction or she did not act upon it. In any event, she did not bleep that doctor, or any of the other avenues available.
By 3.45pm, when the nurse in charge was able to leave her patient and take off the full personal protective equipment she had been wearing, she found from the agency nurse that Mr Jaggs’ blood sugar had dropped to 1.2 and he was unresponsive.
Coroner’s concerns
The agency nurse accepted in court that she should have sought prompt medical attention for Mr Jaggs and that she should have made a contemporaneous medical record of all his blood sugar readings.
However, despite this sub optimal care, she said that she has not received any additional training from you following the incident. And she said that you did not ask her to draft a reflective statement, as the hospital trust had several times requested that you arrange.
The trust has undertaken a great deal of work with its own staff to reduce the likelihood of such a failure in the future. I am extremely concerned that no similar learning is taking place within your agency.
Information checked against the published report and official responses