Foreword
Jump to
In September 2000, I completed the last of three investigations relating to the care of a young woman, Ms J. I have decided to publish the reports of those investigations together because I believe they illustrate lessons that may be learned about the management of a common condition: diabetes. This was not, however, a common case. Diabetes is a serious and life threatening illness: correctly managed, the risk of premature death and complication can be substantially reduced. Yet Ms J died.
A summary of the events, and of my findings and recommendations appear on pages ii-iv. Subsequent pages contain the full text of my investigation reports and the report of an Independent Review Panel, which considered one of the complaints about Ms J's care. The names of the patient, her brother (who made the complaints) and the doctors have been removed in order to preserve confidentiality. I hope they will provide useful material for health professionals, educationalists and those involved in supporting and caring for people with diabetes.
The report is laid before Parliament in accordance with section 14(4)(b) of the Health Service Commissioners Act 1993. Two of the investigations relate to the health service in Wales; although the events pre-date devolution of powers to the National Assembly for Wales, I have provided a copy of the report to the National Assembly.
M S Buckley
Health Service Ombudsman for England
December 2000
