The Francis report, medicines management, and better practice

Abstract

110 Nurse Prescribing 2013 Vol 11 No 3 at any of the four blood tests to be conducted daily, she was to receive Actrapid® insulin. A daily dose of insulin was also to be given. The doctor entered the prescription on a drug chart. A referral to a dietician was also required. When Gill developed suspected Clostridium difficile infection, she was transferred to a different ward. While there, the nursing shift coming on duty failed to undertake appropriate observations or administer insulin when required. Conflict between a failure of handover, or of staff failing to act on what they knew, or a combination, resulted in Gill’s death on 11 April 2007. The ensuing report made it clear that insulin had not been signed as having been given on the morning before her death. Also, while on the ward, Gill had not been given food adequate to her diabetes status. This incident raised issues of concern that were The Francis report, medicines management, and better practice