Diabetic mental health patient dies after being neglected by staff who failed to give him insulin

Hospital staff who failed to give a diabetic man his insulin contributed to his death, The Independent can reveal.

Andrew Clark, who lived with diabetes for the majority of his life, died in February 2022 following a series of “gross failings” at a private mental health hospital in Woking, run by Cygnet Health Care.

Mr Clark, who had schizophrenia and schizoaffective disorder, had spent more than half of his life in mental health units from the age of 35.

According to a record of his inquest which concluded last week, Mr Clark’s blood sugar levels became so out of control that he lost 5kg of weight in the two weeks before his death. He suffered diabetic ketoacidosis, which occurs when a person doesn’t have enough insulin to allow blood sugar into their cells. The body is forced to break down fat for energy and produces an acid called ketone which, in excess levels, can lead to a coma or death.

The inquest found that failings within the unit to manage his diabetes contributed to his death.

Mr Clark’s story comes a year after The Independent revealed healthcare services in England have been handed at least 50 warnings from coroners over patients dying in mental health units due to a lack of basic physical healthcare. A report by experts who advised the NHS, uncovered by The Independent, found a fifth of patients in such units across the country are not receiving basic physical healthcare checks upon admission.

Gross failings

Mr Clark, one of five children, was diagnosed with schizophrenia and schizo-affective disorder when he was 18. In 2004, he was diagnosed with Type 2 diabetes and became reliant on healthcare staff to manage his diabetes.

In January 2021, he was admitted to the Cygnet hospital in Woking. After being on the unit for 10 months, his blood sugar levels became unstable and he required repeated medication called NoVo Rapid, the inquest heard.

Between 20 January and 6 February 2022, Mr Clark’s weight dropped significantly, which should have indicated something was “amiss” with his health, the inquest was told.

According to medical notes presented to the inquest, on the night of his death, he was “confused, unsteady” and was experiencing rapid breathing, as well as high blood glucose levels.

Staff agreed he needed to be transferred to A&E, but this did not happen for another five hours. He later died in hospital.

The jury at the inquest found “repeated gross failings” in the patient’s care after staff did not follow his diabetic medical plan. They found that the appropriate tests of his ketone levels were not carried out.

It was also found that his death was “contributed to by neglect”, adding there was a “systemic lack of accountability, awareness, continuity, and synergy and communications across all staffing levels”.

Mr Clark’s brothers, Mark and Michael Clark, said: “Andrew was a much-loved member of our family. He was kind and devoted to his mother. He loved his dog Kim, walking in the fields and anything to do with cars.

“We are grateful that the jury have recognised that Andrew’s life was cut short due to major failures in his care.”

They said they are concerned over the risk others will lose their lives in the way their brother did.

According to prevention of future death reports, which are issued by coroners when they want to alert bodies such as the NHS to patient safety risks, four patients within mental health hospitals have died with diabetes noted as a factor in their deaths. Two of these patients developed diabetes after being placed on antipsychotic medication.

A spokesperson for Cygnet Lodge Woking said: “We would like to express our deepest condolences to Andrew’s family and all those affected by his loss.

“We take our responsibilities to provide safe care extremely seriously and will always seek to ensure any lessons learned are identified and shared. The importance of physical health checks and liaison with external health professionals in delivering the highest quality care is a priority to us. We are committed to working in partnership to share learning and ensure service user care is always at the heart of everything we do.”