A coroner’s inquest has found the administration of insulin by an agency nurse contributed to the death of a care home resident who suffered from Type I diabetes.
The inquest found 72-year-old Robert Rostron, a former resident of HC-One’s Four Seasons nursing home in Manchester, died from natural causes exacerbated by the administration of insulin.
The court heard how an agency nurse, who was in charge at the home’s Spring Unit, which is no longer in existence, gave Mr Rostron his usual dose of insulin contrary to the guidance of his care plan after taking a low blood sugar reading on September 17 2017.
When the agency nurse returned to check on Mr Rostron a few hours later he was found unconscious and unresponsive.
An ambulance was called and Mr Rostron was taken to hospital. After spending time in two further nursing homes, Mr Rostron died at Fairfield Hospital on 25 June 2018. The coroner concluded the agency nurse’s administration of insulin had made Mr Rostron susceptible to the infections that led to his death. The coroner requested HC-One to review its use of agency staff to prevent future deaths.
An HC-One spokesperson said: “Since the incident, we have worked hard to learn from what happened and to share these learnings across our organisation. For example, we have revised and updated the resources agency staff need in order to ensure kind, high quality care is delivered to all residents, safely and accurately. Additionally, following discussions with agency suppliers, all agency nurses who work in our homes are now required to provide proof of their skills, knowledge and up-to-date training in administering insulin safely.
“We continuously work hard to reduce agency usage, however, as has been widely reported, the sector faces immense recruitment challenges and there are, therefore, occasions when we have to use agency nurses to ensure our residents are suitably supported.