Steven Leslie Rogers · Prevention of Future Deaths report

On 27th August 2015 I commenced an investigation into the death of Steven Leslie Rogers, date of birth 15th July 1969. The investigation concluded on the 13th January 2016 and the conclusion was one of Natural Causes. The medical cause of death was 1a Diabetic Keto-acidosis 1b Type 1 Diabetes Mellitus.

This man was admitted to Stepping Hill Hospital on the 20th August 2015 via the E.D. at 11.21am: he had been seen by his GP who had noted reduced consciousness and confusion in a man who was known to be a fairly unstable Type 1 Diabetic. He was admitted to the wards and overnight he was to have, inter alia, his long acting Levemir insulin. This was accidentally omitted. The following day he was discharged as medically fit, by one of the consultants who had never seen the patient, and he was found dead at home two days later, having died from Diabetic Keto-acidosis.

1. The doctor who discharged the patient from the hospital as being “medically fit for discharge” did so without ever seeing the patient. In his statement to the inquest he says “I am afraid I have never seen Mr Rogers.......... he was seen by two consultant colleagues........... I was asked if he could go home by one of the nurses.....was shown the notes ..... asked the nurse to follow the team’s pre-arranged plan i.e. to discharge the patient. It is noted that Mr Rogers went home by bus”. The fact that a doctor not only discharges a patient in this way but also has no compunction in saying that he has done so in a statement to a Coroner, suggests a fundamental lack of understanding as to the importance of ensuring that all factors are in place for discharge, including medical and social issues.

2. During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin. This was then given later but this meant that his regime had been altered and he would have to re-set the regime at home.