Lancashire TelegraphBlackburn coroner raps ‘chaos’ over diabetic death (From Lancashire Telegraph)

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Blackburn coroner raps ‘chaos’ over diabetic death

Lancashire Telegraph: Blackburn coroner raps ‘chaos’ over diabetic death Blackburn coroner raps ‘chaos’ over diabetic death

A CORONER has raised questions over the ‘chaotic’ treatment of a diabetic man who died from a hypoglycaemic attack.

Simon Neil Eatough, 47, died at Royal Blackburn Hospital after a period in and out of hospital.

At an inquest, Blackburn coroner Michael Singleton said he would write to the hospital about its procedures if he felt its practices were likely to cause a risk of further deaths.

Blackburn Coroner's Court heard Mr Eatough was first diagnosed with diabetes on July 23 after being admitted to hospital. The exact type had not been determined.

He was discharged at around 5pm but by midnight he had been readmitted.

He was discharged again two days later into the care of district nurses, diabetic nurses and his GP. On July 29 he was admitted to hospital with chest pains, vomiting and he had seen blood in his vomit but he was discharged the next day.

The inquest heard he struggled to administer insulin at home due to his alcohol dependency. On August 7, he was taken to the emergency department at Blackburn after suffering a hypoglycaemic attack.

He was discharged but two days later, on August 9, he suffered another attack which caused an irreversible brain injury and his condition deteriorated. He was found unresponsive by his mother, Jean.

Three days earlier, his mother had expressed concerns that he was not managing his diabetes and she had asked for him to be kept in hospital until he stopped drinking but she was told this was unlikely to happen.

Consultant Dr Margaret Christian, who treated Mr Eatough, told the inquest his condition was ‘very serious’ and said the diabetes was not well-managed.

Mr Eatough, of Marsden Road, Burnley, was given medicine to control the symptoms of his alcohol dependency while on the ward, and the hearing was told that, when sober, he was able to correctly administer insulin and test his blood sugar levels.

Recording a verdict of misadventure, Mr Singleton said: “I am required in law to consider if there are a set of circumstances that exist where there is a risk of further fatalities.

“It seems there was chaos. It seems totally chaotic. If there is a system it is not obvious to me.”

Ian Stanley, interim executive medical director at East Lancashire Hospitals NHS Trust, said: “We review the case notes of all patients who have died and will consider our findings in conjunction with the coroner’s findings and associated actions.

“In particular, we will look at communication between the trust and GPs and staff divisions.”

Comments (6)

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9:43am Mon 28 Apr 14

mavrick says...

It is stories like this that reaffirm the decision to put our hospitals in special measures. This was another avoidable death. Have we not got the expertise to diagnose and treat diabetes in the RBH. I am afraid to say this plays straight into the hands of the private vultures that are circling.
It is stories like this that reaffirm the decision to put our hospitals in special measures. This was another avoidable death. Have we not got the expertise to diagnose and treat diabetes in the RBH. I am afraid to say this plays straight into the hands of the private vultures that are circling. mavrick
  • Score: 4

10:14am Mon 28 Apr 14

HarryBosch says...

mavrick wrote:
It is stories like this that reaffirm the decision to put our hospitals in special measures. This was another avoidable death. Have we not got the expertise to diagnose and treat diabetes in the RBH. I am afraid to say this plays straight into the hands of the private vultures that are circling.
Firstly, I extend my deepest sympathies to Mr Eatoughs family on his tragic death. However, it appears to be a little more complex than mavrick is making out. It appears that Mr Eatough was an alcoholic who was struggling to cope with or manage his addiction, when he was then diagnosed with diabetes. Having been initially treated at RBH he has then been discharged. It appears that here is where the continuity of care has fell down. It seems he has gone home, where, without support, he has continued to drink thus causing a deterioration in his diabetes. His problems were complex. This situation wasn't simple or typical. It seems that more needs to be done in similar complex cases, but to say that this case typifies all that is wrong with RBH is wrong. Short of keeping a person in hospital against their will, what should be done? It may indeed be that people with such complex problems DO, in fact, need to be compulsorily kept in hospital until they are stabilised. But, short of keeping them in the secure unit at Pendle View, how do you do that. An alcoholic, seeking their fix could otherwise simply walk out. I do agree that a robust strategy needs to be found for such vulnerable patients. But I submit that this case is not simple and does in no way typify what is wrong with our hospital.
[quote][p][bold]mavrick[/bold] wrote: It is stories like this that reaffirm the decision to put our hospitals in special measures. This was another avoidable death. Have we not got the expertise to diagnose and treat diabetes in the RBH. I am afraid to say this plays straight into the hands of the private vultures that are circling.[/p][/quote]Firstly, I extend my deepest sympathies to Mr Eatoughs family on his tragic death. However, it appears to be a little more complex than mavrick is making out. It appears that Mr Eatough was an alcoholic who was struggling to cope with or manage his addiction, when he was then diagnosed with diabetes. Having been initially treated at RBH he has then been discharged. It appears that here is where the continuity of care has fell down. It seems he has gone home, where, without support, he has continued to drink thus causing a deterioration in his diabetes. His problems were complex. This situation wasn't simple or typical. It seems that more needs to be done in similar complex cases, but to say that this case typifies all that is wrong with RBH is wrong. Short of keeping a person in hospital against their will, what should be done? It may indeed be that people with such complex problems DO, in fact, need to be compulsorily kept in hospital until they are stabilised. But, short of keeping them in the secure unit at Pendle View, how do you do that. An alcoholic, seeking their fix could otherwise simply walk out. I do agree that a robust strategy needs to be found for such vulnerable patients. But I submit that this case is not simple and does in no way typify what is wrong with our hospital. HarryBosch
  • Score: 13

10:30am Mon 28 Apr 14

jimpy0 says...

condolences to his family but --- if people cannot put down the needle or bottle when illness hits, then how is it the hospitals fault.
condolences to his family but --- if people cannot put down the needle or bottle when illness hits, then how is it the hospitals fault. jimpy0
  • Score: 11

1:13pm Mon 28 Apr 14

woolywords says...

As someone whom is wont to point out the many failings of RBH, I have to say, I entirely agree with what Harry Bosch has said, in that it would be to easy to point the finger of blame at the hospital, on this truly sad occasion, it is not their fault.
Short of 24 hour care, I doubt that the outcome in this case would have been any different, as you cannot continue to hammer your liver with alcohol, after it has decided that it can no longer cope and expresses itself with diabetes. It's like ignoring the warning signs on a dangerous road, knowing the risks and ignoring them, completely.
Diabetics are warned about the affects that alcohol has on the sugar levels in the blood, and that, there is an huge risk of collapse and possible death, as a result of drinking even moderate amounts. This should serve as a salutary lesson to all those whom continue to abuse alcohol on a daily basis.

Rather than try to blame someone else, the Coroner would have better returned a verdict of misadventure, much as they do for those whom engage in dangerous practices but ignore the inherent risks.
As someone whom is wont to point out the many failings of RBH, I have to say, I entirely agree with what Harry Bosch has said, in that it would be to easy to point the finger of blame at the hospital, on this truly sad occasion, it is not their fault. Short of 24 hour care, I doubt that the outcome in this case would have been any different, as you cannot continue to hammer your liver with alcohol, after it has decided that it can no longer cope and expresses itself with diabetes. It's like ignoring the warning signs on a dangerous road, knowing the risks and ignoring them, completely. Diabetics are warned about the affects that alcohol has on the sugar levels in the blood, and that, there is an huge risk of collapse and possible death, as a result of drinking even moderate amounts. This should serve as a salutary lesson to all those whom continue to abuse alcohol on a daily basis. Rather than try to blame someone else, the Coroner would have better returned a verdict of misadventure, much as they do for those whom engage in dangerous practices but ignore the inherent risks. woolywords
  • Score: 8

1:28pm Mon 28 Apr 14

heyeyey says...

his addiction, his problem, his fault
his addiction, his problem, his fault heyeyey
  • Score: 3

10:17pm Tue 29 Apr 14

Mypointis says...

This all depends on how accurate the reporting is from the let
I'm not sure a hospital is the place to treat alcoholics, it seems that the care this man received was a pointless waste of time and money as he was not capable of carrying out his side of the deal.
So what are the staff meant to do?
Why was there an inquest in the first place?
Why have the family relinquished their responsibility for their alcoholic family member onto hospital staff?
This inquest raises more questions than answers.
This all depends on how accurate the reporting is from the let I'm not sure a hospital is the place to treat alcoholics, it seems that the care this man received was a pointless waste of time and money as he was not capable of carrying out his side of the deal. So what are the staff meant to do? Why was there an inquest in the first place? Why have the family relinquished their responsibility for their alcoholic family member onto hospital staff? This inquest raises more questions than answers. Mypointis
  • Score: 1

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