A CORONER has criticised a doctor and a nursing team for failures in the care of a 69-year-old woman schizophrenic who died from a diabetic condition.

Anne Brown, formerly of Penwood Lodge Care Centre, Wotton-under Edge, died at Cheltenham General Hospital in May 2008 after going into a diabetic coma.

At her inquest in Gloucester the county coroner Alan Crickmore said her death highlighted "a number of deficiencies in care planning and clinical judgement".

The coroner had been told that as well as diabetes, Mrs Brown had suffered from schizophrenia for many years and this made the management of her diabetes very difficult.

Care manager Paul Saunders told the inquest in Gloucester that Mrs Brown became an in-patient at the Charlton Lane mental health unit in Cheltenham after her placement at Penwood Lodge in Wotton broke down due to her behaviour.

Helen Hickman, said her blood sugar level was lower than usual on May 16.

The following day Mrs Brown was her normal self in the morning and gave no cause for concern.

Sylvia Rhodes, a staff nurse at Charlton Lane, said her blood sugar level was checked on May 17 and found to be very high.

"A colleague contacted the duty doctor in Gloucester, Dr Abayomi Adetola," she said.

"He told us to check it again and when it was still high he said to give Anne her insulin early."

An ambulance was called after her breathing pattern changed later that day and Mrs Brown was taken to Cheltenham General, where she later died.

Dr Adetola told the inquest the impression he got from the staff was that Mrs Brown was not particularly ill.

He admitted that he had not asked if any of the vital signs - pulse and blood pressure - had been taken.

"I was going to go and see her later, and the only reason I did not go must have been because I was busy at Wootton Lawn in Gloucester," he said.

Medical director of 2gether Trust Dr Paul Winterbottom said that since Mrs Brown's death, a new action plan for the treatment of elderly in-patients was being implemented.

He said a new online system of patient records was also about to be launched and in the meantime the trust was improving and auditing the quality of its record keeping.

Mr Crickmore said that when Mrs Brown's blood sugar was so high, Dr Adetola did not ask staff for basic information about her and the nurses did not offer it to him.

"The nurses knew Mrs Brown's history and in my judgement there was a failure on his part and on the part of the nursing staff on duty at the time.

"I am satisfied that this case highlights a number of deficiencies in care planning and clinical judgement but the trust has learned lessons and an action plan is in the process of implementation."

He recorded a verdict of natural causes.