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Insulin OAP was unlawfully killed Insulin OAP was unlawfully killed
(20 minutes later)
An OAP with diabetes who died after a nurse injected her with 10 times too much insulin was unlawfully killed, a coroner has ruled.An OAP with diabetes who died after a nurse injected her with 10 times too much insulin was unlawfully killed, a coroner has ruled.
Margaret Thomas, 85, from Pontnewynydd, Pontypool, died six hours after community nurse Joanne Evans's injection, the Cardiff inquest heard.Margaret Thomas, 85, from Pontnewynydd, Pontypool, died six hours after community nurse Joanne Evans's injection, the Cardiff inquest heard.
The hearing heard the newly-qualified nurse had been upset before her visit. The hearing heard the newly-qualified nurse had used the wrong syringe.
Cardiff coroner Mary Hassell said Mrs Thomas's treatment was grossly negligent.Cardiff coroner Mary Hassell said Mrs Thomas's treatment was grossly negligent.
She said: "With a heavy heart I must conclude that however caring a person the nurse was, the treatment of Margaret Thomas was negligent and that negligence was indeed gross."She said: "With a heavy heart I must conclude that however caring a person the nurse was, the treatment of Margaret Thomas was negligent and that negligence was indeed gross."
The coroner also criticised Gwent Healthcare NHS Trust for which Ms Evans had been working at the time.The coroner also criticised Gwent Healthcare NHS Trust for which Ms Evans had been working at the time.
She said she had been terribly impressed with the dedication of the people giving frontline care but was disturbed about the system they had been working under.She said she had been terribly impressed with the dedication of the people giving frontline care but was disturbed about the system they had been working under.
It was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry Joanne EvansIt was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry Joanne Evans
After the inquest, Mrs Thomas's son, Dr Hywel Thomas, said the family were "surprised" at the verdict and hoped the Crown Prosecution (CPS) would look at the case again.
"I think it's a very brave decision on behalf of the coroner especially after the CPS decided on no criminal action," he said.
He also said Gwent Healthcare NHS Trust had admitted liability and he would be meeting with them next month.
He said he hoped the family would be "reassured that policies and procedures will be urgently implemented to ensure that there will be no reoccurrence of these events".
The three-day inquest heard that Ms Evans had miscalculated in her head the amount of insulin to give Mrs Thomas as she used a regular syringe instead of a specific insulin syringe.The three-day inquest heard that Ms Evans had miscalculated in her head the amount of insulin to give Mrs Thomas as she used a regular syringe instead of a specific insulin syringe.
Ms Hassell said senior trust management had now decided that community nurses should be given a list of equipment to carry in their car.Ms Hassell said senior trust management had now decided that community nurses should be given a list of equipment to carry in their car.
But she said almost two years after Mrs Thomas's death this still had not been produced.But she said almost two years after Mrs Thomas's death this still had not been produced.
The inquest had previously been told that Ms Evans had been upset before her visit to Mrs Thomas because another patient has been difficult and "sexually inappropriate" towards the nurse. Horror
The hearing was also told of Ms Evans's horror at her realisation later that night that she had injected too much insulin into Mrs Thomas. The inquest had previously been told of Ms Evans's horror at her realisation later in the evening that she had injected too much insulin into Mrs Thomas.
She said she reported her mistake to a doctor but the pensioner had already died.She said she reported her mistake to a doctor but the pensioner had already died.
She collapsed on her doorstep after returning from a shopping trip, the inquest was told.She collapsed on her doorstep after returning from a shopping trip, the inquest was told.
Registered blind
Ms Evans told the inquest: "It was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry."Ms Evans told the inquest: "It was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry."
The inquest was also told by a diabetes specialist and a pathologist who examined Mrs Thomas's body that it was likely the overdose led to her death, but they could not be 100% sure.The inquest was also told by a diabetes specialist and a pathologist who examined Mrs Thomas's body that it was likely the overdose led to her death, but they could not be 100% sure.
Ms Evans told the court that she was visiting Mrs Thomas as a favour to community nurses in another area on 2 June, 2007.Ms Evans told the court that she was visiting Mrs Thomas as a favour to community nurses in another area on 2 June, 2007.
Registered blind
She said she did not know until just before she arrived at Mrs Thomas's house at midday that the purpose of the visit was to administer insulin.She said she did not know until just before she arrived at Mrs Thomas's house at midday that the purpose of the visit was to administer insulin.
Mrs Thomas was registered blind and could not inject herself.Mrs Thomas was registered blind and could not inject herself.
Ms Evans said Mrs Thomas gave her an insulin "pen" which she had never used before as they used a syringe and needle where she normally worked.Ms Evans said Mrs Thomas gave her an insulin "pen" which she had never used before as they used a syringe and needle where she normally worked.
She tried using three of the pens but could not get them to work, she said.She tried using three of the pens but could not get them to work, she said.
'Wanted to help'
Ms Evans said she thought she had an insulin syringe in the car, but on fetching it, she discovered it was a regular syringe, not one for insulin.Ms Evans said she thought she had an insulin syringe in the car, but on fetching it, she discovered it was a regular syringe, not one for insulin.
She said she converted the amount wrongly in her mind and injected Mrs Thomas four times with the syringe, but mistakenly gave 10 times the dose of 36 units.She said she converted the amount wrongly in her mind and injected Mrs Thomas four times with the syringe, but mistakenly gave 10 times the dose of 36 units.
The inquest heard she had administered hundreds of insulin injections in her nine months as a community nurse.The inquest heard she had administered hundreds of insulin injections in her nine months as a community nurse.
'Wanted to help'
"I've gone back over it loads of times thinking why and I honestly don't know why," she said."I've gone back over it loads of times thinking why and I honestly don't know why," she said.
"I just wanted to help her. I just want to be a good nurse and help patients and do the best I can for that patient.""I just wanted to help her. I just want to be a good nurse and help patients and do the best I can for that patient."
Following the verdict, Dr Thomas read a statement on behalf of himself and his brother Paul.
"We have heard evidence that in mid-2007 the community nurses in Torfaen showed great care, commitment and team work despite staff shortages and a high workload," he said.
"However, on June 2, 2007, nurse Joanne Evans made a number of very serious errors with catastrophic consequences for our mother, who died later that afternoon.
"Whilst Nurse Evans is obviously very sorry and distressed by her mistakes, it is apparent that there were failings in her training and clinical judgment to request further assistance.
"The verdict today confirms this."