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John Conlan |
Royal Free changes its policy on diabetes following tragic death
THE family of a diabetic former dustman who died at the Royal Free Hospital when his blood-sugar levels crashed are considering legal action after an inquest revealed concerns about his treatment.
John Conlan, 65, from Fletcher Court, off Ingestre Road in Kentish Town, died in August last year as he awaited a bowel operation at the Hampstead hospital.
St Pancras Coroner’s Court heard on Tuesday how his blood-sugar levels had dropped to zero while he was on a nil-by-mouth regime. Mr Conlan died after he was discovered sufferring a seizure in the middle of the night shortly after medical staff had been dealing with a patient having a heart attack on the same ward, the inquest heard.
The Royal Free said guidelines on monitoring the blood-sugar levels of diabetic patients had been changed as a result of Mr Conlon’s death and recommendations had been made for a change in procedure on a national level.
His son Steve said: “Our main aim was to get something changed and, if that happens as a result of this, then I think Dad would have had a smile on his face.
“But we are still disappointed with the way diabetes was treated, and disappointed that there are still some questions we would like answered. His condition was managed very easily at home, by us, with just a little research.”
Pathologist Dr Sebastian Lucas, who carried out the post-mortem examination, told the inquest Mr Conlan’s blood-sugar, or glucose, was non-existent, which he described as “highly unusual”.
He added: “The combination of zero glucose and high insulin is very indicative of hyperglycaemia induced by insulin.”
Coroner Dr Andrew Reid had earlier sent for lab analysis the syringe with which Mr Conlan had been given a dose of insulin. The dose of insulin in the syringe was found to be 50 per cent higher than that ordered by the ward doctor, a verdict disputed by both the staff nurses who had given the dose.
Mr Conlan’s granddaughter, Angela, questioned medical experts throughout the inquest. She asked the ward’s staff nurse: “Could my grandfather have been fitting for quite a while? I mean, who was looking after him, after he had been given quite a bit of sugar and insulin?”
Richard Novell, consultant in colorectal surgery at the Royal Free, took part in the hospital trust’s “Serious Untoward Incident Investigation”.
He said: “It is possible to get a sudden and violent swing from a very high blood glucose to a very low blood glucose. It appears from all the notes that this happened in around 45 minutes. When the patient has no blood glucose, you have a very serious situation.”
The Trust had introduced better training of staff and labelling of drugs since the incident, Mr Novell said, and made “very sweeping recommendations” that government guidelines be changed. He said: “We feel obliged to try to ensure that this terrible situation doesn’t arise again.”
Mr Novell said that although national standards did not require it, dextrose was now given with insulin at the Royal Free to prevent crashes in blood sugar of the sort that killed Mr Conlan.
Medical staff who gave evidence to the inquest all said they had never seen a copy of the Royal Free Trust’s ward policy on diabetes treatment. The treatment that Mr Conlan was given did not conform to the Trust’s policy, and his insulin dose had not been recorded in the drug book. However, his treatment was in line with national standards for diabetes, the coroner ruled.
Dr Reid said: “I am struck that the cause of death might arise elsewhere where hospitals are [also] using recognised regimes.” He reserved his right to contact the Lord Chancellor advising further changes to the way diabetes is treated nationally. |
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