Caliel Smith-Kwami

“The insulin results were delayed, due to a fault with the analyser. Clinicians were not notified by the lab, that the analyser was not functioning. No alert was sent out. Contingency plans could have been put in place, to ensure that alternative arrangements were made for the test to be analysed before [the deceased] was discharged from hospital. The independent expert was critical of the lab's failure to notify clinicians.”

“Test results do not appear to have been chased up before [the deceased]'s discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge.”

“The results of the amino acid profile, which raised the possibility of hyperinsulinism were sent through to the electronic record system on the 9 August 2016. It does not appear that any clinician was aware of this result prior to [the deceased]'s death. The Consultant in Charge of [the deceased]'s care stated that there is no system in place with the electronic record system for highlighting to clinical staff that results are ready. He stated that when paper records were in place, clinicians would result the paper”

“The independent expert stated that in the absence of the insulin and amino acid profile results, a ketone test might have assisted with the diagnosis. He stated that ketone tests can be obtained at the bedside and that this has recently been introduced within his Trust. No witness at the inquest was able to confirm whether the bedside ketone test was available within Barts Health NHS Trust.”