Finding into death of Beryl Eileen Brindley

Contributing factors

• Inadequate monitoring of vital signs and clinical deterioration
• Failure to perform blood ketone testing despite medical recommendation
• Lack of 'sick day' management protocols for Type 1 diabetes
• Poor documentation in medical and nursing records
• No formal assessment of patient's decisional capacity regarding hospital transfer
• Absence of medical review by treating physician between 7-10 December 2016
• Failure to recognize emerging pattern of persistent hyperglycaemia as medical emergency
• Poor communication between facility staff and treating GPs regarding deterioration
• Patient's decisional capacity impaired by severe hyperglycaemia but not formally assessed
• Facility reliance on patient refusal without exploring informed consent or capacity

Coroner's recommendations

1. Implementation of specific medical training on diabetes assessment, management, and response to uncontrolled hyperglycaemia in aged care
2. Adoption of accepted expert guidelines such as McKellar Guidelines for Managing Older People with Diabetes in Residential and Other Care Settings
3. Implementation of improved diabetes charts incorporating all relevant information to maintain treatment overview
4. Implementation of bedside testing for blood ketones for monitoring sick diabetic residents
5. Implementation of policies ensuring medical assessment of medical and cognitive state in patients refusing hospital transfer where no advance care directive precludes treatment
6. Implementation of 'sick day' management plans for diabetic residents including frequent BGL monitoring, ketone testing, fluid maintenance, and insulin adjustment protocols
7. Development of clear escalation protocols linking abnormal BGLs and reduced cognition to clinical escalation pathways
8. Establishment of formal decisional capacity assessment procedures before accepting patient refusal of hospital transfer
9. Enhanced communication protocols between facility staff, treating practitioners, and families regarding resident deterioration
10. Improvement of medical record-keeping with documentation of vital signs, fluid balance, dietary intake, and cognitive observations
11. Tailoring of Advance Care Directives specifically to diabetic conditions and acute medical emergencies