Peter Thompson

“Worsening blood sugar levels in a resident with Type 2 Diabetes can be fatal. Illnesses including infection can cause the progressive condition of Hyperglycaemic Hyperosmolar State. This is what happened with [the deceased]. No one tested his blood sugar levels until the paramedics attended on 5 March 2025. By this time his condition was so severe his prognosis was poor and he did not recover despite treatment. I heard evidence that the earlier treatment is started the better the prognosis. I heard evidence from members of the Ageing Well Team and the Community Nurse that there was an expectation that Care Home staff were carrying out the blood sugar pin prick test. The former manager of the home said that Care Home staff do not do this and do not have the equipment to do this. This test is not complex. It is a test that a resident or a carer would do in their own home. It would form part of a baseline observation for a Type 2 Diabetic patinet who was ill and assist with decision on need to escalate. The continued absence of this test being done by care home staff gives cause for concern that there is a risk that a future death could occur.”

“I heard evidence from the former manager that handovers between shifts do not take place. That staff should look in an individual residents' records. Records do not provide a complete picture of a residents condition and in particular details of staff's ongoing concerns. The priority of the continuing concern about [the deceased]'s deterioration does not appear from the records to have been handed over between shifts. To not have a formal handover at the end and start of a shift gives cause for concern that there is a risk to future death. That delays are caused in escalating a resident's condition.”