Decision Report 201703077

Summary

Mrs C complained about the management of her husband's (Mr A) insulin after he was admitted to Dumfries and Galloway Royal Infirmary for treatment of a stroke. Mr A has a history of diabetes mellitus (a condition that occurs when the body cannot produce sufficient insulin to absorb blood sugar) for which he administers insulin.

In responding to the complaint, the board acknowledged and apologised for a delay in Mr A receiving insulin one evening. The board considered that, during Mr A's admission, staff had followed the correct procedures but more checks of his blood sugar and ketone levels would have allowed staff to act earlier. The board set out a number of measures that they said they had taken regarding staff training and improvements as a result of Mr A's experience.

We took independent advice from a consultant physician specialised in diabetes mellitus. We found that management of the insulin was below the expected standard, given the possibility that diabetic ketoacidosis (DKA, a serious complication of diabetes that occurs when the body produces high levels of ketones) could have been prevented by earlier recognition, more frequent monitoring and more aggressive insulin administration. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff did not specifically inform her or Mr A that he had developed DKA and urosepsis (a secondary infection that develops in the urinary tract). Mrs C said they had only been aware that Mr A had low blood sugar levels. We found that when Mr A developed DKA and urosepsis, there was no record of this having been explained to either of them at the time. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A and Mrs C for the failings in communication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should be aware that early recognition of the warning signs and prompt restorative action should prevent DKA from developing.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.