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Care of a vulnerable diabetic man criticised by coroner
16 June 2014
A coroner has criticised the care provided to a vulnerable man who died after falling into a diabetic coma stating that this contributed to his untimely death.
Type 1 diabetes sufferer Daniel Keane was just 32 when he died at his Eccles flat from diabetic ketoacidosis in January 2011. Daniel had a brain injury caused by an accidental overdose of insulin in November 2009 and was deemed to lack the mental capacity to safely manage his condition himself.
Throughout 2010 Daniel was treated by a variety of hospitals and other institutions as he was struggling with his brain injury and his diabetes. In September 2010 he was admitted to intensive care at Salford Royal Hospital after he was found at home in an unresponsive state.
Staff at Salford Royal Hospital, Salford City Council Social Services, the Meadowbrook psychiatric unit and Daniel’s GP Dr H Singh were all aware of the risk Daniel posed to himself, but no one took responsibility for him and the daily care that he needed was never put in place. Daniel was found dead on 14 January 2011 after the alarm was raised by family members and the emergency services broke into his flat.
Coroner Kevin McLoughlin, who recorded a narrative verdict when the inquest concluded on 9 June at Bolton Coroner’s Court, has criticised several areas of Daniel’s care and said that these made ‘more than a minimal contribution to his death’.
Mr McLoughlin has also sent a Report to Prevent Future Deaths to Health Secretary Jeremy Hunt with concerns about the care Daniel received with the aim of preventing future tragedies. These concerns centre on the role of GP Dr Singh, who he criticised for poor record keeping and said should be investigated for other aspects of the care provided to Daniel.
This includes prescribing antidepressants that Daniel did not need despite never having seen him and his lack of response to a request for an urgent referral to district nurses for Daniel from a concerned clinician.
A specialist solicitor at law firm JMW, represented Daniel’s family at the inquest. She commented: “There were countless opportunities for steps to be taken to prevent Daniel’s death. Daniel’s brain injury and diabetes were a lethal combination and while his family did all they could, Daniel required consistent professional help in his own home.
"His family have waited over three years for the inquest into his death; they have now finally had the opportunity to get some answers and ask why Daniel never received that urgently needed care.
“It had been acknowledged at a Multi-Disciplinary Meeting that Daniel required visits from carers four times a day to manage his condition in addition to the family support he was receiving. However despite desperate pleas from his family the care package was never established and Daniel was effectively abandoned by those with the power to intervene."
“Daniel’s death was an avoidable tragedy and an example of how catastrophic the consequences can be for patients with complex needs if they are allowed to fall through the cracks.”
Daniel grew up and went to school in Windermere in the Lake District and enjoyed a happy childhood. Before he sustained his brain injury he had worked as an IT systems manager in Manchester. However after sustaining the brain injury he had severe cognitive impairment and was unable to work.
His mother Janet McCallum Hartley, a 54-year-old secondary school head of music frequently travelled from her home in the Lake District to Manchester to support Daniel and attend meetings about his care. Family in Manchester also regularly checked on Daniel however he required daily specialist care from medical professionals to ensure that his diabetes was kept in check.
Janet commented: “Daniel’s death has been completely devastating for the whole family. We have always felt that it was an accident waiting to happen but it seemed like no matter how much we pushed for help we were consistently met with brick walls. It is very hard for me to understand how his death was allowed to happen when there were so many warnings and the agencies involved were aware that he was in a crisis situation.
“We learned during the course of the inquest that there are other diabetic adults who have suffered from brain damage in similar circumstances to Daniel; we can only hope that the investigation into Daniel’s death can improve services for other patients in similar circumstances and prevent any other vulnerable patients from suffering the same fate.”
The coroner found that the following issues with Daniel’s care contributed to his death:
• A lack of leadership in the management of his case with no one taking responsibility for co-ordinating the multiple agencies involved.• The absence of a clear plan to deal with Daniel’s care after he discharged himself from hospital on 9 September 2010 and again on 27 September.
• Two ineffective multi-disciplinary meetings which were not attended by key participants and actions badly managed which allowed matters to drift for eight weeks before Daniel’s death.• The absence of a clear role for Daniel’s GP Dr Singh. Dr Singh had never even seen Daniel even though he was a patient with complex needs who had been registered with his practice since October 2009. The GP not only prescribed antidepressants to Daniel that he did not need but also did not act upon a request from a clinician concerned about Daniel’s well-being for an urgent referral to district nurses.
• Steps taken to check Daniel was managing his diabetes were not enough to provide reassurance as to his safety.
For more information or to arrange an interview, please contact Kelly Hindle on the details below:
D. 0161 828 1868
Note to Editors
JMW Solicitors LLP is a leading Manchester law firm and offers a broad range of legal services to both commercial and private clients.JMW’s Clinical Negligence team is headed up by leading lawyer, Eddie Jones.