Michael Quinn

serum glucose level of greater than 6 to 9 and a post-operative level of 11.1mmol. I also heard that one hospital trust used a figure of 20 as the highest acceptable level and Diabetes Scotland quoted a level of 14mmol. (2) It is clear to me that there is a great deal of confusion about what is an appropriate level for patients such as Mr Quinn and the optimal blood glucose level that should be achieved in patients, diabetic or otherwise, prior to surgery. While I did not find at the Inquest that Mr Quinn’s blood glucose level of 13mmol was a factor in the infection that led to his death, I am nevertheless concerned that the written policy in place at the time does not mirror that of the national guidelines and is also at odds with other published research articles. (3) I am directing this report to you because I understand that the method adopted by Circle Hospital was based on the policy of your Trust which took the lead in these matters. In those circumstances, I would invite the Trust to review its policy to determine whether the current recommended levels are appropriate in light of other current guidelines and evidence based research. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 25th September 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of Mr Quinn. You are also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 3rd August 2015 Peter J. Bedford Senior Coroner for Berkshire