Colleen Alice FLETCHER · Prevention of Future Deaths report

On 30 June 2021 I commenced an investigation into the death of Colleen Alice FLETCHER aged 82. The investigation concluded at the end of the inquest on 30 June 2022. The conclusion of the inquest was natural causes.

Colleen Fletcher was diagnosed with Type 2 diabetes in 1999. She was insulin dependent. Due to her underlying condition of Alzheimer's disease, Mrs Fletcher was cared for in a residential care home and her insulin was managed daily by the community nursing team. On 26 January 2021, Mrs Fletcher’s blood glucose levels began to rise and continued to do so over the course of the next few days, measuring 13.2 mmols on the 27 January and 17.2 mmols on 28 January. It did not respond to the prescribed insulin doses which were being administered. Mrs Fletcher was not referred to the GP or the Diabetic Specialist Nurse. On 29 January 2021 Mrs Fletcher’s blood glucose level was 29.6 mmols. She became hyperglycemic and collapsed. An ambulance was called but Mrs Fletcher went into a diabetic coma before the Ambulance arrived and sadly passed away at 10.31 hrs on 29.01.2021 at the Hinckley Park Care Home.

I understand that patients who have volatile glucose levels have the availability of pre-issued prescriptions for rapid acting insulin.

Those patients, like Mrs Fletcher, whose glucose levels are relatively stable don’t have the availability of the same prescription. Should their glucose levels begin to rise they would have to be referred to a GP, reviewed by that GP, possibly asked to monitor further and/or a prescription issued and collected from the surgery/chemist, before increased insulin could be administered. I was told that this could take in excess of a 24 hour period, during which time a patient’s glucose levels could continue to rise. I was told that raised glucose levels in and of themselves would not be considered an emergency for the ambulance service until a patient went into a state of hyperglycaemic collapse, which, as in the case of Mrs Fletcher, was a point of no return.

I understand that discussions are taking place to ensure the availability of fast acting insulin to be prescribed for all patients who are diabetic (regardless of volatility in their blood glucose levels) and that whilst progress has been made for those whose readings are volatile there is still work to be done to have the standby provision of bolus injections available for patients otherwise stable, whose glucose levels could at any point become unstable (by contracting an infection for example).

I consider that this is an essential tool for nurses on the front line to have at their disposal in treating effectively rising glucose levels and preventing hyperglycaemia and subsequent death.