contained within the narrative attached, but in brief -

1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support.

On 21 February, a bank nurse worked alone in the morning, though was joined by another agency nurse at lunch time, with only a senior nurse in the office.

On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients.

Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse.

There was a conflict of views among the nurses that day about who had primary care of Mr Taylor.

2. There was no protocol for the loss of notes and drug chart. Attempts by the ward staff to locate these were not prompt, focused or sustained. The notes and chart were later found simply in a drawer on the ward.

3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic.

When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff.