Recurance · prevention of future deaths reports
Pre-inquest brief
Omission of long‑acting insulin dose during inpatient care
The earlier warning
Pamela Pattison · 23 Mar 2015 · John Pollard, Manchester (South)
“ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin'”
judiciary.uk/prevention-of-future-death-reports/pamela-pattison
What was promised
Stated action 1 · response to Pamela Pattison (23 Mar 2015) · stated timescale: none stated
“The Trust has also implemented an electronic inpatient referral form for patients needing review, which provides a more robust method for all ward areas to request help or support in managing patients with diabetes.”
What recurred
- 20 Jan 2016 · Steven Rogers · John Pollard · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Pamela Pattison · 23 Mar 2015
“ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin'”
Later · Steven Rogers · 20 Jan 2016
“During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin”
What happened next
No web check of the stated actions has been published for this chain.