Maidstone & Tunbridge Wells NHS: Failings led to grandfather's death

Bosses at Maidstone and Tunbridge Wells NHS Trust (MTW) have issued an apology after an inquest heard how a series of failings by the hospital resulted in the death of a 57-year-old man.

Jonathan McCarthy was admitted to Tunbridge Wells hospital late last year after complaining of chest pains. He was then transferred to the hospital’s specialist diabetes ward, where he remained for a number of weeks.

An inquest into Mr McCarthy’s death heard that on 6^th October 2018, he was given an insufficient dose of insulin to lower his blood sugar levels, which were described as ‘off the chart’.

Despite Mr McCarthy raising multiple concerns with hospital staff, he was repeatedly ignored, and no senior medical staff were alerted to his increasingly deteriorating condition.

Mr McCarthy sadly passed away in the early hours of 7^th October, after suffering diabetic ketoacidosis - a potentially life-threatening complication of diabetes mellitus which results from a shortage of insulin; in response, the body starts to burn fatty acids, which produces acidic ketone bodies.

Following his death, the trust launched an investigation and has admitted to a total of seven breaches of duty, including:

• Failure by nursing staff to administer the correct dose of insulin
• Failure to review Mr McCarthy
• Failure to ensure ketone analysis was done in the 48 hours before his death
• Inadequate observations
• Inadequate monitoring of blood sugar
• Inadequate nursing care
• Inadequate mechanisms for escalation

The inquest into Mr McCarthy’s death took place at Archbishop’s Palace in Maidstone.

Recording a narrative conclusion, coroner Roger Hatch said: "On the balance of probabilities, I find that the trust failed to correctly monitor Mr McCarthy’s blood sugar and ketone testing.

“There was a failure to administer the correct dosage of insulin and there was inadequate nursing care and a failure to escalate to the medical team when it was clear this should have been done.

“The death was due to the failure of MTW NHS Trust to check frequently for high blood sugar levels or test for ketone, and as a result of no action being taken, he developed diabetic ketoacidosis from which he died.

“May I express my sympathies to the family.”

Mr McCarthy’s wife, Amanda, added: “He warned them that if they didn’t give him more insulin, he would go blind, lose his leg, or it would kill him, and that’s what happened. It was disgusting."

Following the inquest, management at the trust have said lessons have been learnt from the tragedy and added that new policies – such as a 'traffic light' system to indicate when blood sugar levels are within a safe, medium and dangerous category - were being implemented across the ward.

Helen Budge, a Senior Clinical Negligence Solicitor here at Potter Rees Dolan, comments:

This is a terrible sequence of failings as a consequence of which a man has died. The monitoring of blood sugar levels in diabetic patients is basic nursing care and it is quite shocking that Mr McCarthy has lost his life in these circumstances.

Read how Helen helped to secure £4 million in compensation for man left paraplegic here

Read how medical negligence led to young diabetic man needing leg amputation here

Helen Budge is a senior clinical negligence solicitor with Potter Rees Dolan. Should you have any queries about clinical negligence issues and wish to speak with Helen or any other member of the team please contact us on 0161 237 5888.