District nurse referral forms reviewed after coroner’s concerns over patient death

An NHS Trust has reviewed its district nursing referral forms following the death of a patient who was not seen by a district nurse because they were unable to access him.

Central London Community Healthcare NHS Trust has reviewed its district nursing referral forms to ensure the next of kin and emergency contact details for patients are ‘mandatory fields’ and are completed at triage.

It said it had also undertaken engagement events with around 420 to reinforce the need to ensure ‘clinical records are comprehensive in all situations’.

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This comes in response to concerns raised in a Prevention of future deaths report around a district nurse being unable to access a patient who later died from consequences of diabetes.

An inquest held on 17 December last year in North London heard that Asher Blackman, 72, died on 21 September 2025 in hospital after collapsing at home.

‘It is unclear why he became so hypoglycaemic as no district nurse visited the evening before to provide his insulin injection,’ said coroner Andrew Walker in the report.

‘It is likely than an imbalance between his food and insulin caused the hypoglycaemia.’

He added: ‘Had the district nurse been able to get access to Mr Blackman, a blood sugar reading would have been taken and an opportunity to treat Mr Blackman was therefore missed.’

Mr Walker wrote to Central London Community Healthcare NHS Trust expressing his concerns that the initial assessment for Mr Blackman by the district nursing team did not record his next of kin details or what to do should the district nurse not be able to gain access.

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He added that the trust’s policy following no access did not take into account the need for police involvement where the life of the patient may be at risk through non access.

Responding to the coroner, the trust’s chief nursing and people officer confirmed that, following the report, the trust reviewed the district nursing referral forms, ensuring that next of kin and emergency contact details are now mandatory fields to be completed at triage.

In addition, a long-term plan has been put in place to improve the visibility of this information on the electronic system district nurses use.

Addressing Mr Walker’s second concern about the police not being contacted, the trust stated that, while police involvement is not routine, it is both ‘justified and expected’ where a failure to gain access gives rise to ‘immediate or escalating concerns regarding patient safety or risk to life’.

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It said it is now reviewing this policy by placing ‘greater emphasis on the immediate escalation of a “no access” visit where a patient is assessed as being at significant clinical risk, including cases requiring critical interventions such as blood glucose monitoring and insulin administration’.

As well as these changes, the trust undertook a programme of engagement events which were attended by 420 staff members.