• Report no:
    201609022
  • Date:
    October 2018
  • Body:
    Tayside NHS Board
  • Sector(s):
    Health

Summary

Miss C complained about the care and treatment her late brother (Mr A) received from Tayside NHS Board (the Board).  Mr A had type 1 diabetes with recurrent episodes of hypoglycaemia (when the level of sugar (glucose) in the blood falls below a set point) and a learning disability.  Mr A, who had been a patient with the Board’s diabetes service since he was a teenager, died unexpectedly aged 38 years.

Miss C complained there was a failure by the Board to appropriately assess and treat Mr A and to take account of how his learning disability affected his ability to manage his diabetes care.

We took independent advice from a consultant diabetologist.

Our investigation found that the management of Mr A’s type 1 diabetes, given his learning disability, would have been challenging.  However, in view of Mr A’s recurrent often severe hypoglycaemic episodes and his apparent lack of awareness of his condition and how to manage it effectively, the Board should have focused on the management of his hypoglycaemia, listened to the concerns of Mr A’s family and carried out a full assessment of Mr A’s awareness of hypoglycaemia.  The Board did not provide us with evidence that they did so.

We found that consideration should have been given to investigating whether there were any other possible underlying additional contributing conditions for Mr A’s recurrent hypoglycaemic episodes as recommended in national guidelines and the recognised associations with other autoimmune diseases, given his family history of autoimmune disease. 

While there had been attempts by the Board to change Mr A’s insulin regime in the years prior to his death, which were unsuccessful, there was no evidence that consideration was given to trying other treatment or of a referral to other centres with more expertise in severe hypoglycaemia to try and address and mitigate against Mr A’s recurrent severe hypoglycaemia. 

Although it could not be definitely said that Mr A’s death was as a consequence of a severe hypoglycaemic episode, it was possible given the circumstances of his unexpected death and as recurrent severe hypoglycaemia has been strongly linked as the potential basis for sudden death in persons with type 1 diabetes.

We considered the lack of action by the Board in their management of Mr A’s diabetes represented a serious failure in his care and treatment and we upheld the complaint.

While we acknowledged and welcomed the remedial action the Board has taken on the need to better support people with diabetes and who have a learning disability, we considered this did not go far enough to address the root causes of the issues raised in this case.  In particular, we were of the view the Board had not addressed the underlying clinical issues concerning the assessment and management of patients with type 1 diabetes and recurrent severe hypoglycaemia.  We made a number of recommendations to address the failings in this case.

Redress and Recommendations
The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Miss C:

What we found What the organisation should do Evidence SPSO needs to check that this has happened and the deadline

The assessment and management of Mr A’s type 1 diabetes fell below a reasonable standard.

There was a failure by staff to comply with national guidance, in particular, in relation to assessing and managing Mr A’s hypoglycaemia.

There were omissions in record-keeping in relation to documenting Mr A’s hypoglycaemic awareness

Apologise to Miss C for the failure: 

  • to reasonably assess and manage Mr A’s type 1 diabetes, in particular, in relation to his hypoglycaemic awareness;
  • to properly take into account national guidance in their management of Mr A; and
  • in record-keeping in relation to documenting Mr A’s hypoglycaemic awareness

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-andguidance

A copy or record of the apology

 

By:  24 November 2018

We are asking the Board to improve the way they do things:

What we found What should change Evidence SPSO needs to check that this has happened and the deadline
The assessment and management of Mr A’s type 1 diabetes fell below a reasonable standard

The Board should have and apply a clear and standardised policy for the assessment and management of all patients with recurrent severe hypoglycaemia.

Clinical case conferences should be held for challenging cases with hypoglycaemia (and/or challenges in care in those with a learning disability) as part of the Board’s care quality programme

Evidence :

  • that the Board have a policy in place for the assessment and management of patients with severe hypoglycaemia which takes into account relevant national guidance;
  • the Board has carried out a review of the care, assessment and management of all patients with severe hypoglycaemia in line with this policy; and
  • clinical case conferences for challenging cases with hypoglycaemia are held and included as part of the Board’s care quality programme

By:  24 December 2018

There was a failure by staff to comply with national guidance, in particular, in relation to assessing and managing Mr A’s hypoglycaemia awareness Staff should be aware of and take into account in their clinical practice the Board’s policy and relevant national guidance and standards in relation to the assessment and management of patients experiencing problems with hypoglycaemia.  If in a particular case, the Board decides not to follow national guidance and standards, the reasons should be clearly documented

Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning

By:  24 December 2018

There were omissions in record-keeping in relation to documenting Mr A's hypoglycaemic awareness Records should be maintained in accordance with good medical and nursing practice

Evidence that this report has been shared with relevant staff and managers in a supportive way for reflection and learning

By: 24 December 2018

The Board told us they had already taken action to fix the problem.  We will ask them for evidence that this has happened:

What we found Outcome needed What we need to see
The Board accepted that they had not met all of Mr A’s needs throughout his time with the diabetes service The Board said they had reviewed their approach to patients who have diabetes and a learning disability and their need to better support them

An update on the Board’s diabetes and learning disability improvement plan and ‘Diabetes Out There’ project

Evidence as to how patients are made aware of the diabetes managed clinical network website

By:  24 December 2018