Wearable sensor
17. Mr A told us how important it was to his son that he was able to monitor his own glucose levels. He explained that Mr C became frustrated when he was not able to do this. Mr A said his son was able to do this on a previous admission, and so should have been able to do this during this hospital stay.
The Trust complaint response said it was unable to find documentation about Mr C using a sensor to monitor his blood glucose levels, nor any conversations with staff he wished to do so. Mr A told us he had never wanted Mr C to self-administer his insulin, just to be able to wear his sensor.
18. The Joint British Diabetes Societies guidance says ‘The responsible nurse and the patient should agree, on admission, the circumstances in which the patient should self-manage. An agreement form should be signed by both the patient and a registered nurse’.
19. The NICE guidance NG17 says: ‘ Throughout inpatient admission, respect the personal expertise of adults with type 1 diabetes in managing their own diabetes and incorporate this into routine ward-based blood glucose monitoring and insulin delivery.’
20. The Code says ‘You assess need and deliver or advise on treatment or give help (including preventative or rehabilitative care) without too much delay, to the best of your abilities, on the basis of best available evidence. You communicate effectively, keeping clear and accurate records and sharing skills, knowledge and experience where appropriate.’
21. We can see that in the previous admission, the Trust carried out an assessment of Mr C’s preference to self monitor. This did not happen on this admission.
22. Our advisers agreed the failure to carry out an assessment of whether Mr C wanted to, or was able to, monitor and administer his own insulin was not in line with expectations. We find it was not in line with the guidance quoted in paragraphs 18, 19 and 20.
23. It was not reasonable for the complaint response to say there was no documentation about Mr C using a sensor to monitor his blood glucose levels, nor any conversations with staff he wished to do so. This is because the Trust did not act in line with the guidance to assess this.
24. We looked to see whether this failing had an impact on Mr C. Our nursing adviser told us it was unlikely he would have been assessed as suitable to manage his own monitoring using a sensor. This is because there is evidence on the records to show he was hypoglycaemic (had low blood glucose levels) from early in the admission, and had skin integrity issues that would have made self-monitoring and self-administration unsuitable.
25. Our physician adviser agreed with this view. They said as Mr C was an emergency admission, and was being prepared for surgery, the clinical circumstances meant self monitoring would not have been suitable.
26. Whilst the failing did not have a clinical impact on Mr C we can see there was an impact on Mr A. He was left thinking there could have been a different outcome. This concern might have been prevented if the Trust had carried out the assessment, so there was clear information about the decision making.
27. We do not think the Trust has recognised this failing, and we make recommendations as outlined from paragraph 55.
Managing diabetes
28. Mr A told us he didn't think the staff had the skills to look after Mr C on the ward he was on. He said it was a non diabetic ward and they didn't have the right level of specialism or knowledge. He said if the Trust was monitoring Mr C’s diabetes properly he would not have had a hypoglycaemic episode.
29. Mr C was placed on a surgical ward. Our physician adviser explained this was appropriate for the medical condition he was admitted with, and the Trust arranged input from the diabetes team when needed.
30. On 23 April, the day after admission, Mr C had a hypoglycaemic episode. The NHS website explains this can happen because diabetes medicines lower the blood glucose level, and they can sometimes make it go too low. It says this is common if the patient takes insulin, and sometimes there is no obvious reason why a low blood glucose level happens.
31. The Trust arranged for the specialist diabetes nurse to assess Mr C. They drew up a detailed care and treatment plan on 23 April. This was in line with the CPOC guidance which says relevant details relating to the patient’s diabetes should be recorded, and that the patient be referred to ‘diabetes team or physicians’ if there is severe hypoglycaemia.
32. The medics took a multidisciplinary approach to managing Mr C’s diabetes and involved the diabetes nurse (who saw Mr C both pre and post operatively). They also involved the endocrine registrar (diabetes specialist medic). This was in line with GMC guidance which says ‘refer a patient to another practitioner when this serves the patient’s needs’ and ‘consult colleagues where appropriate’.
33. The Trust took a multi-disciplinary approach by involving the ward team, the renal team and the specialist diabetes nurse. We consider this was in line with the guidance outlined in paragraph 32.
34. There were some parts of the way the Trust managed Mr C’s diabetes that were not in line with guidance. As outlined in paragraph 31 the diabetes nurse drew up a plan. They also instructed staff to check ketones. High ketones can be caused when insufficient insulin causes the body to break down fat for energy. This can lead to ketoacidosis, a condition causing acidic blood, dehydration, and organ damage.
35. The staff carried out this instruction, checking Mr C’s blood glucose levels 25 times that day. The team also took specialist advice from the endocrinologist. Our nursing adviser told us this was in line with the Trust’s decision support tool for insulin use.
36. Our lead clinician agreed this happened as it should after the hypoglycaemic episode. The decision support tool says ketones should be checked if blood glucose is high and rising, and this happened. They explained there is no guidance that says how often ketones should be checked. Mr C’s blood glucose levels then stopped rising. On this occasion the actions of the Trust were in line with the guidance.
37. However, the records show one other occasion when the Trust did not follow the decision support tool. The Trust should have continued to follow the advice on 25 April, when the blood glucose level showed an elevated result. This did not happen and this was not in line with the decision support tool. The Trust should have arranged for ketones to be checked again here and it was a failing this did not happen.
38. We considered whether there was a clinical impact from this failing and decided there was not. Our lead clinician reviewed all blood glucose results and found subsequent tests showed blood glucose had settled to a more satisfactory level overall. They told us that the reason for checking the ketones was to see if diabetic ketoacidosis was developing (when blood glucose levels remain dangerously high). There is no evidence this occurred in the seven days preceding Mr C’s death.
39. We were also concerned the Trust did not act as it should have in relation to Mr C’s food intake, which is important in diabetic care. The food intake pages are poorly completed, and the records show Mr C had poor dietary intake.
40. Our nursing adviser said they would have expected the nursing team to have referred Mr C to an appropriate colleague to help with this, such as a dietician. This would have been in line with the Code which says: ‘Respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate’.
41. There is no evidence the Trust took any action to help with dietary intake, and it has not recognised this failing.
42. We looked to see whether there was any evidence this led to a poorer outcome for Mr C. As outlined in paragraph 39, our lead clinician said if there had been an impact from the failure to refer for dietary support they would have expected to see abnormal blood sugar results in the seven days before Mr C’s death, and we did not.
43. We cannot say there was a clinical impact from the failings. Mr C’s death was unexpected and we have seen no evidence it was linked to the failings. We understand there has been an impact on Mr A as his worries that things were not done as they should be continued to cause him concern. We make the recommendations as outlined from paragraph 55 to remedy this.
Visiting
44. Mr A told us Mr C was on his own in the hospital. He said if he had been able to go in and visit it would have helped him so much. We know Mr A looked after his son so well when he was poorly and we recognise how difficult this must have been for him.
45. There was special NHS guidance about visiting at the time, because of COVID-19. This guidance only allowed visits in certain exceptional circumstances. These included, patients at the end of their life, where there was a ‘family bubble’ or where it was necessary for people to communicate.
46. We understand how much Mr A wanted to visit to offer support. Despite this, the guidance restricted visiting to exceptional circumstances. Mr C did not fall into those categories, even though he relied on his father for support ordinarily.
47. At that time hospitals were asked to take action for the protection of everyone, staff, visitors and patients. The NHS guidance said ‘Careful visiting policies remain appropriate while coronavirus continues to be in general circulation and organisations can exercise discretion where Covid rates are higher. The health, safety and wellbeing of our patients, communities and staff remain the priority’. In this circumstance it was reasonable for the Trust to decide Mr A should not visit.
DNAR
48. Mr A said his son signed the DNAR decision because he was confused. Mr A told us he always helped Mr C with his decision-making and should have been including in making this decision. Mr A told us about some issues Mr C had in 2014 which showed he did not have capacity to make such decisions.
49. The records show there was no reason to doubt Mr C’s capacity to make his own decisions about the DNAR. Mr A pointed to an occasion in 2014 when Mr C was judged to not have capacity. He shared a report with us from 2015 that said ‘mild or even moderate cognitive deficits cannot be ruled out’. Our physician adviser explained we could not apply evidence of a lack of capacity from several years earlier as reason for why a patient was not able to make a decision some years later. Capacity is judged for each decision a patient makes about their care and treatment at that time.
50. The Mental Capacity Act says ‘assume a person has the capacity to make a decision themselves, unless it's proved otherwise’. There is nothing to suggest that on this occasion, Mr C did not have the capacity to make that decision.
51. The NHS website on mental capacity gives a list of conditions that people may have that could mean they lack capacity, these include a severe learning disability and dementia. It makes clear that the fact someone has one of these health conditions does not necessarily mean they lack the capacity to make a specific decision.
52. Our physician adviser said the records are clear Mr C was deemed to have capacity for the decision, and none of the factors above applied to this decision.
53. We understand why Mr A was concerned, as there is no evidence he was told about the decision. Clearer communication about this may have reassured Mr A about the decision making. In relation to the issue of consulting or involving Mr A, there were no failings as there is no evidence Mr C did not have capacity to make that decision, and so nothing to say Mr A needed to be involved in making it.