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Jonathan McCarthy

22 May 2019 · Coroner Roger Hatch · North West Kent
Check this reportOriginal

The coroner's concerns

  1. 1. inadequate blood sugar and ketone monitoring

    “The Trust failed to correctly monitor the blood sugar and ketone testing of [the deceased] [name redacted]”

  2. 2. incorrect insulin administration

    “The Trust failed to administer the correct does of insulin”

  3. 3. inadequate nursing care and delayed escalation

    “There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out”

Responses

2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error