PFD report

Jonathan Richard McCARTHY · Prevention of Future Deaths report

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Issued 22 May 2019•North West Kent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to administer the correct dose of insulin
    Part of recurring concern: Unsafe medication administration
  2. Failure to correctly monitor blood sugar and ketone testing
    Part of recurring concern: Failure to reliably measure and monitor blood glucose levels
  3. Failure to escalate to the medical team
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Unreliable escalation by care staff for required medical attention
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

  1. Action

    Develop and introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
  2. Action

    Disseminate the blood-monitoring guidance through presentations at remaining Trust Clinical Governance days.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
  3. Action

    Deliver ward-based diabetes-monitoring training through specialist nurses and link nurses.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to administer the correct dose of insulin

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to correctly monitor blood sugar and ketone testing

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”

Is this part of a recurring concern?

Yes — Failure to reliably measure and monitor blood glucose levels.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to escalate to the medical team

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it; Unreliable escalation by care staff for required medical attention.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate nursing care

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.

Verbatim wording from the response

“The Trust has also been out to tender for a blood glucose and ketone testing meter that has the capability of linking into the existing clinical observation monitoring tool (Nervecentre) which would record and escalate results accordingly. In addition blood ketone testing machines have been purchased and assigned to key locations in the trust with the aim to ultimately have them on each ward. The Emergency Departments on both sites have these in place and appropriate training has been rolled out to the nursing staff. In addition the Diabetic Nurse Specialists also carry ketone testing machines to support access and training to the ward staff as and when required.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate the blood-monitoring guidance through presentations at remaining Trust Clinical Governance days.

Verbatim wording from the response

“The new guidance will continue to be disseminated throughout the Trust by way of short presentations at the remaining Trust Clinical Governance days over the coming months delivered by either the Diabetes Specialist Nurses or the lead Diabetic Consultants.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 3 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver ward-based diabetes-monitoring training through specialist nurses and link nurses.

Verbatim wording from the response

“Ongoing adhoc ward training is to be delivered by the Diabetes Specialist Nurses to raise awareness of the new Blood Monitoring guidance on the wards with support from identified link nurses. In addition we have worked with the Directorate and Communications team to develop a strategy to raise awareness throughout the organisation in regard to the process of close diabetic monitoring. Some of this work included the use of the Patient Safety Calendar to focus on the key elements of diabetic management, a launch of the Blood Monitoring Guideline and bespoke Training days for Nurses and Clinical Support Workers.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 3 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Purchase and deploy blood-ketone testing machines to key locations, with emergency-department nursing training and specialist-nurse support.

Verbatim wording from the response

“The Trust has also been out to tender for a blood glucose and ketone testing meter that has the capability of linking into the existing clinical observation monitoring tool (Nervecentre) which would record and escalate results accordingly. In addition blood ketone testing machines have been purchased and assigned to key locations in the trust with the aim to ultimately have them on each ward. The Emergency Departments on both sites have these in place and appropriate training has been rolled out to the nursing staff. In addition the Diabetic Nurse Specialists also carry ketone testing machines to support access and training to the ward staff as and when required.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement an organisation-wide diabetes-monitoring awareness strategy using the Patient Safety Calendar, guideline launch and bespoke training days.

Verbatim wording from the response

“Ongoing adhoc ward training is to be delivered by the Diabetes Specialist Nurses to raise awareness of the new Blood Monitoring guidance on the wards with support from identified link nurses. In addition we have worked with the Directorate and Communications team to develop a strategy to raise awareness throughout the organisation in regard to the process of close diabetic monitoring. Some of this work included the use of the Patient Safety Calendar to focus on the key elements of diabetic management, a launch of the Blood Monitoring Guideline and bespoke Training days for Nurses and Clinical Support Workers.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 3 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide monthly induction training for clinical support workers, registered nurses and junior doctors on diabetic monitoring, equipment, escalation and referrals.

Verbatim wording from the response

“Ongoing monthly training has been in place for new Clinical Support Workers and Registered Nurses and this is undertaken during their first weeks on induction to the trust where diabetic management is highlighted in bite-sized sessions. This is delivered by the Diabetes Specialist Nurses on both sites. This demonstrates the use of equipment (by the Point of Care Team), the new algorithm for the recognition and management of hyper- and hypo-glycaemia and how to request in-patient referrals to the Diabetes Team and escalate for medical attention. The Blood Glucose Guideline also forms part of the Junior doctors induction programme which is also undertaken by the Diabetes Team.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 1 · response
Published 14 August 2019

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the pharmacy drug-chart auditing process and disseminate serious-incident learning through the monthly Medicines Safety News editorial.

Verbatim wording from the response

“The Pharmacy Department are undertaking a review of the auditing process in regard to Drug charts as this was not identified in the case of Mr McCarthy and is being discussed and addressed at their team meetings. The Serious Incident findings are being highlighted in their monthly learning editorial (Medicines Safety News).”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver targeted staff training and share case learning on testing, abnormal-result response and escalation to medical or diabetes teams.

Verbatim wording from the response

“As outlined in response to question (1), this aspect of Mr McCarthy’s care has been addressed directly with the staff concerned on those on the ward with specific training and the learning from Mr McCarthy’s case has been shared. The introduction of the algorithm, the raised awareness of the importance of testing and acting/escalating abnormal results have been outlined and incorporated into the new guidance. This includes the element of how and when to escalate to medical teams or diabetic nurse specialists for assistance and review.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the approved blood-glucose monitoring guideline, including traffic-light interpretation, hypoglycaemia management and escalation procedures.

Verbatim wording from the response

“It was identified during the Serious Incident investigation that the staff concerned were unsure of the appropriate procedures relating to the monitoring of blood sugar and ketone testing therefore a Trust Guideline for capillary blood glucose monitoring for inpatients and day cases with Diabetes Mellitus over the age of 16 years has been written and approved by the Medical Specialities Directorate. This guideline is in keeping with the standard set by the National Inpatient Diabetes Audit. The guideline has been out for wide consultation with comments from clinicians across the trust being received. Contained within the Guideline is a coloured “traffic light” risk tool to assist staff on the wards to interpret the results of blood sugar and ketone testing, with recommended actions to undertake and escalation as appropriate.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 1 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Include dedicated blood-glucose-guideline training and case learning in junior-doctor induction programmes.

Verbatim wording from the response

“Junior doctor induction programmes will now include dedicated training in the Blood Glucose monitoring guideline and the key learning points from Mr McCarthy’s case.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver additional registered-nurse and clinical-support-worker study days using the case and related serious incidents as teaching scenarios.

Verbatim wording from the response

“In addition two further specific study days have been booked for Registered Nurses and a half day for Clinical Support Workers where the above will be discussed in more depth and the use of Mr McCarthy’s case and any other related Serious Incidents used as teaching scenarios.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Present the case and its learning at the joint Medicine Clinical Governance Meeting.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
  2. 2

    Equip every ward with hypoglycaemia treatment boxes, algorithms, medications and audit forms for specialist-nurse follow-up.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Present the case and its learning at the joint Medicine Clinical Governance Meeting.

Verbatim wording from the response

“This was highlighted with the medical team at the time of the Serious Incident investigation. A presentation of Mr McCarthy’s case was delivered at the joint Medicine Clinical Governance Meeting in June 2019.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Equip every ward with hypoglycaemia treatment boxes, algorithms, medications and audit forms for specialist-nurse follow-up.

Verbatim wording from the response

“We have ensured that there are “Hypo boxes” on every ward which contain the new algorithm, oral and IV medications for the treatment of patients having hypoglycaemic attacks. There is also an audit form for completion so that the Diabetes Specialist Nurses can follow these cases up and identify any trends.”

Source location

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Page 2 · response
Published 14 August 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026