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  • Prevention of Future Deaths report: Sandra Finch (12 June 2023)

    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Emma Serrano, Coroner
    • 12/06/23
    • Health and care staff, Patient safety leads


    On the 9 October 2021 an investigation was carried out into the death of Ms Sandra Diane Finch, a 44 year old woman who had a history of Type 1 diabetes mellitus. The investigation concluded at the end of the inquest on 3 May 2023. The conclusion of the inquest was a narrative conclusion of ketoacidosis due to insulin depravation contributed to by neglect.

     The cause of death was:

    • 1a) Ketoacidosis
    • 1b) Uncontrolled Type 1 Diabetes Mellitus
    • 1c) Insulin depravation.


    Sandra Diane Finch had recently had a dental procedure and was also recently prescribed antibiotics for an infection. It was accepted by clinicians that this can cause a Type 1 diabetic to need more insulin than they would normally need. On the 3 December 2021, Sandra's glucose levels started to rise.

    On the 4 December 2021, Sandra called the West Midlands Ambulance Service and told them she was feeling more sleepy, her glucose was high and she had been vomiting. The categorisation of this call was category 3. This meant she was a medical emergency and required an ambulance. However, before an ambulance could be dispatched a clinical review was required by the CV team.

    The team was under staffed and had no time limit attached for an assessment. As such, an attempt for an assessment did not take place until 10 hours later. At 12:47 on the 5 December 2023 the decision was made by the team to categorise the ambulance request as a category 2 and dispatch an ambulance. This arrived at Sandra Diane Finches address at 13:08 and she was found to have passed away as a result of ketoacidosis.

    The view of clinicians was that had the ambulance been despatched within the accepted time limit for a category 3 ambulance, Sandra Diane Finch would not have died when she did.

    Matters of concern

    1. That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly. 
    2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays.
    Prevention of Future Deaths report: Sandra Finch (12 June 2023) https://www.judiciary.uk/prevention-of-future-death-reports/sandra-finch-prevention-of-future-deaths-report/
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