James Hedge
PFD Report
All Responded
Ref: 2016-wp25334
All 4 responses received
· Deadline: 15 Sep 2016
Sent To
Response Status
Responses
4 of 4
56-Day Deadline
15 Sep 2016
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) The evidence showed that the advice and guidance in relation to the use of the insulin pump, which is one of several on the market, does not adequately highlight the dangers of misuse and the potential consequences which may follow if the device is not used correctly – in this case, the incorrect insertion of the insulin cartridge leading to a leak and loss of insulin at a time when blood sugars were high.
(2) The evidence showed that the education of diabetic patients does not adequately focus upon the potential consequences of failing to properly manage a hyperglycaemic state and in particular, how quickly such a state can become life threatening.
(2) The evidence showed that the education of diabetic patients does not adequately focus upon the potential consequences of failing to properly manage a hyperglycaemic state and in particular, how quickly such a state can become life threatening.
Responses
Report Sections
Investigation and Inquest
On 27th January 2016 I commenced an investigation into the death of James Michael HEDGE aged 18. The investigation concluded at the end of the inquest on 6th July 2016. The conclusion of the inquest was that of a narrative conclusion and the medical cause of death was 1a.Diabetic Ketoacidosis.
The narrative conclusion was “James Michael HEDGE died from the effects of diabetic ketoacidosis in circumstances in which he had high blood sugar levels and there was a leakage in the insulin pump he was using. The most likely cause of that was the incorrect usage of the machine.
The narrative conclusion was “James Michael HEDGE died from the effects of diabetic ketoacidosis in circumstances in which he had high blood sugar levels and there was a leakage in the insulin pump he was using. The most likely cause of that was the incorrect usage of the machine.
Circumstances of the Death
James Michael HEDGE was a type 1 insulin dependent diabetic and had been from the age of three. After concern for his welfare, his room at Cardiff University was entered and he was discovered deceased on his bed. It was noted by one of the attending officers that an insulin pump, which was connected to him, was “beeping” A subsequent investigation of the pump revealed that the insulin cartridge had been fitted incorrectly and had leaked.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.