Leslie Hurwood

26 March 2025

Private and Confidential
Mr Dixey
Assistant Coroner
The Guildhall
St Giles’ Square
Northampton
NN1 1DE

Dear Mr Dixey

Medical Directors Office
Cliftonville
Northampton
NN1 5BD

Switchboard: 01604 634700

Mr Leslie Hurwood Inquest: Regulation 28 Report

I write to formally acknowledge receipt of the above Regulation 28 Report issued to this
Trust and to provide a response detailing the actions we have taken.

You  have  highlighted  concerns  regarding  insulin  not  being  administered  to  diabetic
inpatients at the appropriate time, which could compromise its effectiveness and pose
a risk to patient safety. Additionally, you have raised concerns that the training provided
does not always ensure correct practice is followed.

We have reviewed these issues thoroughly and appreciate the opportunity to address
your concerns. We are committed to ensuring safe and effective diabetes management
and  are  taking  necessary  steps  to  strengthen  both  clinical  practice  and  training
provisions.

Immediate actions:
The senior nursing team immediately visited ward areas to reinforce the importance of
administering  specific  types  of  insulin  before  meals  and  to  identify  any  immediate
concerns regarding the management of patients with diabetes.

To  strengthen  communication  and  awareness,  all  wards  conduct  shift  huddles,
providing staff with an opportunity to raise patient safety concerns and share essential
updates.  In  response  to  this  issue,  a  dedicated  huddle  sheet  was  created,  outlining
insulin administration best practices and key safety information. These huddle sheets
were  used  throughout  the  week  to  ensure  all  staff  received  the  information,  with
signatures  collected  to  track engagement.  The  information  was also  shared  with  the
Multidisciplinary Team to ensure alignment across care teams.

To assess current practices and identify areas for improvement, the Trust immediately
conducted an audit of all patients receiving insulin. This ensured that medication was
being  administered  correctly  and  allowed  for  the  targeted  deployment  of  dedicated
diabetes training where needed.

 To  sustain  improvement,  a  poster  and  screensaver  campaign  has  been  launched,
displaying key insulin safety reminders in ward areas.

Ongoing actions
A  multi-disciplinary  meeting  was  convened  to  review  issues  raised  in  your  report,
together with the formation of dedicated improvement groups to target further areas of
quality  improvement.  The  meetings  also  allow  for  organisational  oversight  of  the
concerns raised to ensure adequate improvements are made.

 Training
Staff training is being reviewed to ensure that the content is appropriate and that the
timings of insulin administration forms part of the fundamental training provided to
staff.  The role specific and mandatory  training  is also being reviewed  and insulin
administration  considered  for inclusion. We  are  in  the  final stages of  securing an
insulin safety e-learning package which will be validated through regular audit data.

  Oversight
As  described  above,  the  senior  nursing  team  has  developed  a  comprehensive
audit to review insulin administration, which will be integrated into our established
regular ward safety audits. The audit findings will be accessible to ward leaders,
senior nursing leadership, the patient safety team, and Diabetes Specialist Nurses
to  ensure  ongoing  monitoring  and  continuous  improvements  in  safe  insulin
administration. These results will also be incorporated into the safety dashboard,
which  is  reported  through  the  Trust’s  governance  framework  for  oversight  and
accountability. Additionally, the Diabetes Specialist Team will conduct an additional
monthly audit to provide specialist oversight and further assurance.

To  enhance  collaboration  and  oversight,  the  Diabetes  Team’s  fortnightly  safety
meeting  has  been  expanded  to  include  senior  nurses  from  each  Division,
Pharmacy, and the Patient Safety Team. Furthermore, the Medicine and Urgent
Care Division will actively participate to support and drive quality improvements,
ensuring a multi-disciplinary approach to diabetes care and patient safety.

  Documentation
The Trust is implementing a new Electronic Prescribing Medication Administration
System (EPMA) in May 2025. The Diabetes team are involved in the development
of  this  system  to  ensure  that  there  are  inbuilt  safety  features  for  insulin
administration.

Whilst we await implementation of EPMA, paper-based drug charts have also been
reviewed  to  ensure  that  the  time  of  administration  of  insulin  can  be  clearly
documented in order to support the audit mechanisms introduced.

  Policy
Whilst not a contributory factor in Mr Hurwood’s case, we have decided to review
our  policy  relating  to  the  self-administration  of  medication  It  is  recognised  that
diabetic patients who can self-administer their insulin should be encouraged and
supported to do so.

   Protected Mealtimes
Mealtimes are protected within our hospitals. This is a period where all ward-based
activities stop, where clinically appropriate, to enable staff to assist patients with
their  nutritional  needs.  This  will  be  re-launched  to  include  ensuring  the
administration of insulin at this time.

I hope this provides you with assurance that the Trust has taken, and continues to
take, proactive steps to improve insulin care for our inpatients. These actions are on
track to be completed and will be monitored by reports to the Insulin Oversight Group
and reported up to Patient Safety Committee and by exception to Quality and Safety
Committee in Common.

Finally, I would like to express my apologies for the issues identified in your Report
and to reaffirm our commitment to continually work to improve patient safety.

Yours sincerely

Medical Director