Type one diabetic who died in care home was neglected by staff
PUBLISHED: 16:53 19 June 2019 | UPDATED: 12:37 20 June 2019
A type one diabetic who died in a care home was neglected by members of staff in the lead up to his death, an inquest heard.
James Delaney, 37, was found "blue" and "unresponsive" in his bedroom at Sapphire House in Bradwell on the morning of July 28, 2018.
The inquest into Mr Delaney's death concluded at Norfolk Coroner's Court in Norwich on Wednesday.
His medical cause of death was given as diabetic ketoacidosis (DKA) - a condition which causes harmful substances called ketones to build up in the body when it starts to run out of insulin.
Senior coroner Jacqueline Lake concluded Mr Delaney's death was as a result of "natural causes aggravated by neglect".
Mrs Lake said the 37-year-old was "clearly unwell" in the lead up to his death and staff at the care home should have sought medical attention.
The inquest previously heard Mr Delaney had not taken his insulin for three days before he died and it was the care home's protocol for a general practitioner (GP) to be called if a resident had not taken their medication for 24 hours.
A senior care worker at Sapphire House said she was aware he had not taken his insulin for three days but did not call a GP because it was 'not her responsibility'.
In her conclusion, Mrs Lake said: "If this is not a case of neglect I do not know what is."
After the inquest, Mr Delaney's mum, Roberta Conway, paid tribute to her son.
She said: "I'm over the moon with the result.
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"I am so pleased we have stopped anything like this happening ever again and this is James' legacy.
"James was a difficult person to know but I will always remember his laugh.
"I think about him 100 times a day."
Mrs Lake said she was confident the care home had made the "much needed changes of culture" following Mr Delaney's death and accepted many members of staff had a good relationship with him.
The changes included staff being given "ring-fenced" time to read and understand patients' care plans and documents.
Mrs Lake did raise concern over the "continued confusion" staff had when understanding the right time to call a GP when medication had been missed.
In a statement released after the inquest Sapphire House said: "We will, of course, reflect on the outcome as a team and continue to work hard to provide a comfortable, compassionate and happy home for everyone in our care."