DOI 10.14296/deeslr.v14i0.2541
This product is not for diagnostic use; all patient diagnostics should be based on results reported by the point of care instrument.See page 1-2 of the manual.
The Precision Web database provided all computer evidence (the only evidence) against the nurses.
The original of this seems to be no longer available on the NHS web site but an archived local copy is here.
It contains the following minutes, with my brief comments shown like this:
6.6.9 In support of greater understanding of issues associated with the blood glucometry system it is recommended that all staff investigated, together with those staff involved in the investigations, the case note reviews, internal assurance review process and in the management of the Precision Web system, should be required to read the report prepared by Professor Thimbleby for the court, together with the Judge’s ruling, and complete a written reflection on the contents. — This didn’t happen, with the exception of Gunneberg's notes which are available archived on this page above.
It is also recommended that Professor Thimbleby is invited to engage in a filmed recording for educational purposes and to inform the Board on the findings which were presented to the courts. Action within 3 months from approval of the report. Christine Morrell, Director of Therapies and Health Science Exec Lead June 2017. — This didn't happen at all.
POCT advise that Professor Thimbleby was asked to review the Abbott meters and Precision Web by ABMU HB in 2013 by Steve Coombe, POCT manager was asked to meet with him and Steve Coombe to explain the operation of the meter. There was also a visit arranged to Singleton Hospital where POCT coordinator (LP) showed him the system in working practice on a ward. Professor Thimbleby did not report any concerns in 2013. — I wrote this review of the Abbott glucometers prior to the court case. I did not have access to the Abbott Precision Web system (or refer to it in my report), which is where all the faults lay — so, unsurprisingly, the review makes no mention of any concerns relevant to the case as it hadn’t yet happened.
Subsequently Professor Thimbleby became an expert witness for the defence. June 2017 .' Angela Hopkins presented a lessons learned talk which was attended by Clinical Director of Laboratory Medicine who produced feedback and a reflective report in regard to Professor Thimblebys report — I attended this meeting. The Clinical Director’s talk to the full lecture theatre at the Princess of Wales hospital completely ignored every finding of the court case — in particular they had clearly not read (or chose to deny) the Judge’s ruling that the Hopkins report had asked them to reflect on. I started to stand up and was physically not allowed to speak (I would have contradicted the Clinical Director who had claimed there was nothing for the hospital to worry about because three nurses had been convicted — so the problem was solved and the hospital remained blameless).