Concerns have been raised about the interaction between hospitals, GPs and district nurses after the death of an 86-year-old diabetic.
Yesterday, north Northumberland coroner Tony Brown recorded a verdict that Henry Hill, known as Ronnie, from Hipsburn, died from pneumonia, likely to have been the result of a hypoglycemic episode (low blood sugar) due to poor control of diabetes.
Mr Brown also said that he was planning to make a rule 43 report, which aims to prevent further deaths, to Northumbria Healthcare NHS Foundation Trust expressing concerns over communication and co-ordination between the hospital, GPs and district nurses.
“I think there’s a risk of this type of scenario happening again,” he added.
However, the inquest did hear that work had been undertaken by the trust since Mr Hill’s death.
Dr Nick Lewis-Barned, clinical head of service for diabetes at the trust, said: “We have taken it really, really seriously.
“We don’t like someone dying from hypoglycemia, it makes us sit back and think quite hard about it.”
Mr Hill died in hospital on March 22, 2009, after his son Bob found him lying on his kitchen floor at around 11am two days before.
He was hypoglycemic and in a state of hypothermia – his evening meal from the night before was uneaten and his bed hadn’t been slept in, suggesting he had been there all night.
His family were concerned about an accidental overdose 10 times the required dose of insulin two months before his death, although witnesses confirmed this had no bearing on his death, and the once-a-day regime of insulin and blood glucose monitoring that Mr Hill was on.
Welcoming the verdict, son Bob said: “I’m pleased at the mention of poorly-controlled diabetes within the verdict because, in my view, the overdose was the beginning of a catalogue of errors that nobody in the service picked up for two months,” adding that he hoped lessons learned would mean it doesn’t happen to anyone else.
Forensic pathologist Dr Nigel Cooper and diabetes specialist Dr John McKnight felt that the most likely cause of Mr Hill’s collapse was hypoglycemia, while Dr Lewis-Barned said that Mr Hill seemed to be able to tell when his blood sugar was low and that its onset would take minutes not seconds, so he was unsure.
However, all of the experts agreed that the once-daily regime was unusual or not normal, as it would not provide a clear view of how his blood-sugar levels changed over 24 hours, and it remained unclear who made this decision.
The inquest also heard that the overdose in January 2009 occurred because a district nurse, Paula Coogan, had to use a standard 1ml syringe rather than an insulin syringe, which was not provided when Mr Hill was discharged from Wansbeck General Hospital.