Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0308, written 20 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jul 2022 |
|---|---|
| Reference | 2022-0308 |
| Deceased | Colleen Fletcher |
| Coroner | Fiona Butler |
| Coroner area | Rutland and North Leicestershire |
| Category | Other related deaths |
| Organisation named | Leicestershire Partnership NHS Trust · University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO:
Executive NHS Leicester
Leicestershire and Rutland Integrated Care Board
1 CORONER
I am Miss F BUTLER, Her Majesty's Assistant Coroner for the coroner area of Rutland and
North Leicestershire.
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
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.
4 CIRCUMSTANCES OF THE DEATH
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.
5 CORONER’S CONCERNS
During the course of the investigation my inquiries revealed matters giving rise to concern. In
my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
I understand that patients who have volatile glucose levels have the availability of pre-issued
prescriptions for rapid acting insulin.
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you (and/or your
organisation) have the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 14 September 2022. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Family of Mrs Fletcher
Leicestershire Partnership Trust
Hinckley Park Care Home
Care Quality Commission
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or of
interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest.
You may make representations to me, the coroner, at the time of your response about the
release or the publication of your response by the Chief Coroner.
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
9
Dated: 20 July 2022
Miss F Butler
Her Majesty’s Assistant Coroner for Rutland & North Leicestershire
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From the office of: , Chief Nursing Officer and Deputy CEO Based At: Our Ref: Your Ref: County Hall, Leicester 16 September 2022 Miss F Butler Her Majesty’s Assistant Coroner of Rutland and North Leicestershire Dear Miss Butler, Re: Regulation 28 following the death of Colleen Alice FLETCHER I write on behalf of (Chief Nursing Officer, NHS Leicester, Leicestershire and Rutland Integrated Care Board) in response to the Regulation 28 Notice issued to the NHS Leicester, Leicestershire and Rutland Integrated Care Board (“LLR ICB” or “the ICB” hereafter) following the investigation into the death of Colleen Alice Fletcher. The concerns highlighted by the Court are summarised as follows: Availability and pre-issue of rapid acting (Bolus) insulin for patients whose glucose levels are relatively stable but who may experience unstable blood glucose readings at a specific time for which Bolus insulin may be required (for example if they have an infection). The ICB hopes that the coroner’s concerns are addressed by the response set out below. As a commissioner of healthcare, LLR ICB works in collaboration with primary care service providers (including GP Practices), and community and acute providers to continuously look for ways to improve provision of healthcare for our patient population across Leicester, Leicestershire and Rutland. This includes the provision of healthcare for diabetic patients. The ICB has established a Leicester, Leicestershire and Rutland wide task and finish group to review the existing clinical pathway for management of Hyperglycaemia in Care Homes. This task and finish group draws on clinical experts across the system specialising in diabetic care and includes: • Consultant in Endocrinology and metabolic medicine (University Hospitals of Leicester NHS Trust) • GPs with a specialist interest in diabetes care and care homes • Lead specialist diabetes nurse - inpatient and community team (University Hospitals of Leicester NHS Trust) • Community nursing team (Leicestershire Partnership NHS Trust) • Managerial commissioning leads for diabetes and care homes (NHS Leicester, Leicestershire and Rutland Integrated Care Board) • Clinical educator (Leicestershire Partnership NHS Trust) • Eden training team (Leicester Diabetes Centre) Room G30, Pen Lloyd Building, County Hall, Glenfield, Leicester, LE3 8TB Tel: 0116 295 7572 / 0116 295 3405 www.leicesterleicestershireandrutland.icb.nhs.uk NHS Leicester, Leicestershire and Rutland is the operating name of Leicester, Leicestershire and Rutland Integrated Care Board The key aims and objectives of establishing this group includes: Start date Action Completion date Notes 1. To review and improve the existing pathway and August 2022 End of guidance for the LLR Management of Hyperglycaemia in care homes 2. To update and circulate the amended pathway and associated guidance and ensure the patient pathway is available for all staff in an easy-to-follow flow chart. 3. To develop a communication plan to embed the revised pathway among health care professionals and care home staff. This will include providing, 1st October 2022 September 2022 15th October 2022 1st October 2022 - 15th October 2022 Next meeting to finalise the pathway 29/09/2022 a. Clarity to staff in all settings on their responsibilities for the management of diabetic care b. appropriate training and support for health care professionals and care home staff so that they are to be able to identify and manage care home residents that are experiencing raised blood sugars. 5. Prioritising availability and administration of rapid acting insulin for the patient where it is deemed necessary by linking the pathway to our existing Home First service for a faster response. Home First is our expert rapid response team that are on hand within two hours to help keep older people well at home and avoid hospital admissions, this will ensure that diabetic care home residents who are experiencing an episode of unstable glucose will receive administration of insulin bolus within 2 hours of a referral. 4. Review the existing insulin authorisation form and make it mandatory for primary care and hospital clinicians to use Insulin authorisation forms to quality assure safe prescribing of insulin including authorisation for bolus insulin in the community. Insulin requests will only be accepted with the completion of the revised insulin authorisation forms which will include frailty scores and the recommended PRN rapid acting insulin dosage guidance depending on the patient’s frailty score and continuous blood glucose reading. August 2022 March 2023 1st October 2022 15th October 2022 A series of training via roadshows currently in progress. Training for improving diabetic care in care homes had already been identified as a priority for 2022-23 Started and in progress. Home First have agreed to support and will be embedded into the revised pathway. September 2022 Mid - October 2022 Started and in progress - revised form has agreed with Leicestershire Partnership Trust. Authorisation forms now include that every patient on insulin will have the prescribing of ad-hoc rapid acting insulin written into their record. 6. Supporting the development of a system wide business June 2022 case to access funding to expand the use of continuous glucose monitors devices for patients in a care home who are living with diabetes. This will assist the care home staff with monitoring and management of their resident’s glucose levels on a day-to-day basis. 7. Further scope any gaps in support / guidance to care homes for the effective management of patients with diabetes and look to access service development funding for a pilot project October 2022 Business case in development for submission for system review in October 2022 Aug 2022 Nov 2022 Started and in progress. Aim for all work relating to improving insulin management and support to care homes to be completed by Nov 2022 I hope that this information is helpful in responding to the concerns raised. Please do not hesitate to contact me or should you need any further assistance. Yours sincerely Deputy Chief Nursing Officer
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