Patient with type 2 diabetes dies at hospital due to “avoidable hypoglycemic episode”, coroner says

A 77-year-old woman with type 2 diabetes died after hospital staff failed to carry out basic checks of her blood glucose levels.

Patricia Chapman had been rushed into University Hospital, Durham with a broken hip, before later being admitted to Sedgefield Community Hospital. She died overnight after slipping into a coma.

The hospital has been criticised by a coroner, while Patricia’s family are reportedly set to take legal action against the hospital.

Conducting basic checks

“Pat”, as she was known to her family, had lived with type 2 diabetes for over 20 years.

In July 2013, she suffered a broken hip after a fall at her home. After entering Sedgefield Community Hospital, Pat lost consciousness as her blood sugar levels fell.

Following an emergency glucagon injection being administered, proper checks were not carried out as to what Pat ate and drank afterwards. She was reportedly given Lucozade and a snack, but there was no official record of this.

Pat was left for six hours overnight and fell into a coma. She could not be revived at 05:00 when her blood sugar reading was 3.2 mmol/L. 45 minutes later, an ambulance was called, while staff tried to raise Pat’s blood sugar levels by rubbing a gel inside her cheek.

Home Office pathologist Dr. Mark Egan concluded that Pat lost consciousness and died due to low blood glucose levels.

Avoidable hypoglycemic episode

Durham coroner Andrew Tweddle told the inquest into Pat’s death that the hospital had not provided adequate training and that she died due to “avoidable consequences of an avoidable hypoglycaemic episode”.

“The nurse in charge failed to ensure that regular checks of her blood sugar were undertaken…and failed to appreciate the importance of regular observations, failed to ensure the deceased had adequate blood sugar reserves, and failed to ensure the deceased’s safety through the night,” Tweddle said.

A file was given to the Crown Prosecution Service after two nurses were investigated by Durham Police, but there was insufficient evidence to bring charges.

The family is reportedly taking legal action against the hospital, according to Chronicle Live. Amanda Dobson, Pat’s daughter, told the coroner her mother never had any problems with her diabetes in hospital before.

A spokesman for Co Durham and Darlington NHS trust said: “Lessons have been learned as a consequence of her death and substantial changes have been and continue to be made to the delivery of care across all community hospitals to safeguard against further incidents.”

In 2014, an 87-year-old man died in hospital after being given incorrect insulin treatment. Following Dennis Heath’s death, Walsall Manor Hospital put in place an action plan for the distinct management of low blood sugar in patients with type 1 and type 2 diabetes.

Picture: www.clugston.co.uk

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Jack Woodfield

Jack is Editorial Manager of Diabetes.co.uk. He works hard, plays fair and sleeps whenever possible. He has type 1 diabetes, doesn't mind being called a "diabetic", and once won a talent show for dancing to Dario G’s 1997 hit “Sunchyme”.

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