Joan Osborne
26 Mar 2018 · Coroner Jane Gillespie · Nottinghamshire
The coroner's concerns
1. non‑compliance with blood glucose monitoring and insulin administration
“The nursing home staff did not seek assistance from the Dementia Outreach Team when Mrs [name redacted] compliance with her blood glucose levels and insulin prescription deteriorated at the end of 2016 onwards.”
2. missed diabetes nurse appointment
“The nursing home did not make any members of staff available for the pre-arranged appointment with the Diabetes Nurse on 28.11.2017 resulting in a missed opportunity to seek assistance with Mrs [name redacted] compliance.”
3. delayed medical intervention for insulin refusal
“The nursing home staff did not seek medical assistance for Mrs [name redacted] when she refused to have her insulin prescription over an extended period, on two separate occasions, leading to her hospitalisation on 12.08.2017 and 22.08.2017.”
4. lack of management notification of insulin refusal
“The nursing home staff did not alert anyone in the management team to the fact that Mrs [name redacted] had refused to have her insulin prescription for a period of 3 days prior to her hospitalisation on 22.08.2017.”
5. inadequate record keeping
“The nursing home records in respect of Mrs [name redacted] were inadequately completed.”
6. failure to recognise deteriorating condition
“The nursing home staff did not recognise the need, nor seek help, for Mrs [name redacted] deteriorating condition on 22.08.2017 and did not seek the urgent attention of her GP upon his usual attendance at the home on that date.”