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Negligence at Addenbrooke's

Significant delays and inability to maintain Averil’s glucose level led directly to a worsening of her condition.
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Averil was transferred to Addenbrooke's after several days at Norwich and Norfolk University Hospitals. As her specialist inpatient care had been there, it was hoped that the doctors there would be able to provide better, specialist care than those at NNUH, and that they might be able to save her. In the event, however, her treatment was significantly delayed, and her condition worsened dramatically until it was too late.

Averil's Treatment at Addenbrooke's

Averil arrived at Addenbrooke's N2 ward before 3pm on the 11th December 2012. She was extremely weak, and it was particularly urgent that she received the appropriate treatment. It had been suggested that she undergo nasogastric feeding, but at the point of her admission to the ward, at 8pm, the decision was made to defer this overnight.

While she had been on a glucose drip beforehand, this was removed overnight, but the staff were left with instructions to monitor her glucose level, and maintain it overnight before starting feeding the next morning. By the next morning, Averil was unresponsive and slipped into a coma, her blood sugar having dropped severely overnight.

There were several clear inadequacies in her care at Addenbrooke's, which have been acknowledged in the report prepared by the Serious Incident report team at the hospital:

  • While Averil arrived at the hospital before 3pm, the night team - which starts at 8pm - was left to admit her and carry out blood tests, which were only taken after 10pm. The simple "prick" test for blood sugar had not been carried out at any point until after 11pm.
  • The junior doctor on duty had responsibility for a number of wards, with a number of other very sick patients. This limited the time and care available to Averil, and put her at risk, as the later blood tests were difficult to obtain.
  • The Mental Healthcare Assistant who remained with Averil overnight was not adequately trained to (and did not) recognise that her condition had deteriorated rapidly, and consequently earlier intervention was not possible.
  • The staff at Addenbrooke's failed to use the Mental Health Act to section Averil in order to provide treatment. While she had agreed to feeding the following morning, she refused all but the smallest amount of glucose gel given to her when it became apparent that her blood sugar level was dangerously low.