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In 2012, MX, who was 78 and had been living independently, was admitted to hospital after a fall, there were some complications, and on discharge she was placed in a care home. She was assessed as needing residential, not nursing home care, but as there was no bed available in the residential part of the home she was admitted to the nursing unit as an interim measure, this meant that she received nursing care from the home’s own nursing staff. She was discharged from the hospital with a possible pressure ulcer and a catheter as well as her chronic conditions of Diabetes and Chronic Obstructive Pulmonary Disease (COPD) but without a discharge summary.

Within the home, care plans were in place for care in relation to MX’s plaster cast and for her catheter care but not for the other issues that were critical in relation to her nursing care including pressure ulcers, her food intake, her diabetes and the potential for her to have a hypoglycaemic episode, her medication and her blood pressure.

About 8 weeks after being admitted to the home, it was documented that MX’s blood pressure was low, she was feeling sick and her blood sugar was very low. These were all indications that MX was seriously unwell and deteriorating, but were not recognised as such. Sadly, MX died early the following day.

The review was unable to determine if MX’s death could have been prevented, but it is clear that there were many factors that, if changed, could have made a difference in the last few days of her life. The review found that the staff involved in the care of MX were not uncaring in their interactions but they lacked the resources, skills and perhaps the clinical leadership to maintain systems that could support and enable good care.

The independent author put it simply “it is not good enough just to show a caring attitude, you also have to be responsibly informed and make clinically sound decisions”.

Learning from the Review

  • Work was not delegated or spread across senior staff in the home, the manager was expected to be the clinical lead for pressure ulcers, and Diabetes as well as managing the home, and it was unclear how she received clinical supervision and guidance.
  • MX did not have a food chart, which meant that her erratic eating went un-noted and this may have contributed to her unstable blood sugar levels in the weeks leading up to her death
  • MX did not have a care plan in relation to her Diabetes or how to proceed if she had a hypoglycaemic episode
  • MX’s GP asked for regular blood sugar testing, but this did not happen, the home said the testing machine was not working and they did not take action to replace or recalibrate the machine. There was no chart to record her blood sugar readings. There are a lot of people with Diabetes in care homes and proper management is a core aspect of their care.
  • MX’s GP had asked for her blood pressure to be monitored regularly, the day before she died MX had very low blood pressure and the staff were advised by her GP that this was a cause for concern, however no further blood pressure checks were taken throughout the ensuing day
  • Procedures and best practice were not followed; in this case a 999 call should have been made as soon as it became clear that MX’s low blood sugar reading was not quickly returning to normal after she had been given hypostop (a concentrated glucose gel).
  • On the night in which MX died no-one recognised that her condition was rapidly deteriorating and that she was dying, as a result her relatives were not called, and they were not given the opportunity to be with her when she died.
  • While completing this review the care notes were found to be either incomplete or missing. Nursing homes are busy places but the lack of proper record keeping is suggestive of a service that was not reliably collecting the kind of detailed information that underpins good nursing care – As soon as MX died her files should have been secured.
  • This review was delayed as the concerns raised were treated as a complaint, not safeguarding.

Implications for practice:

  • Senior staff should have appropriate clinical supervision, from someone with whom they can discuss difficult cases and seek advice on best practice. Key specialist roles, such as Diabetes Lead, should be shared amongst the staff.
  • Specific care plans should be in place for all on-going conditions, including; Diabetes, Chronic Obstructive Pulmonary Disease (COPD) and wound care.
  • All residents should have a food chart, correctly and regularly completed, A recognised tool such as the Malnutrition Universal Screening Tool (MUST) should be used in all care homes to assess the risk of malnutrition and to inform care planning.
  • Routine training specifically addressing treatment of Diabetes should be given to nursing and care staff in care homes, skills should include how to take and record blood sugar levels, how to use blood testing machines, what to do if the machine is not working and how to manage a hypoglycaemic episode. Blood sugar levels should be regularly recorded from the day of admission.
  • Care home staff must follow advice and instructions given by doctors and other specialists.
  • Accurate and effective care records must be completed by care home staff and all homes should have a secure system for their storage.
  • Care homes should have a clear “end of life” procedure, including initiating end of life discussions with the person and their relatives to ensure they have an opportunity to express their wishes in advance.
  • All care homes should have a complaints procedures with a clear system in place to identify what should be dealt with as a safeguarding referral instead of a complaint, or a clear route to seeking advice if unsure.

The full executive summary of this review can be found

Information posters, outlining the action to take in the event of Hypoglycaemia or Hyperglycaemia have been designed to assist Care Home staff and can also be found on the website

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