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| Insulin OAP was unlawfully killed | Insulin OAP was unlawfully killed |
| (10 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 used the wrong syringe. | The hearing heard the newly-qualified nurse had used the wrong syringe. |
| Cardiff coroner Mary Hassell said Mrs Thomas's treatment was negligent. The CPS is to review the case. | |
| 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. |
| 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. | 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. | "I think it's a very brave decision on behalf of the coroner especially after the CPS decided on no criminal action," he said. |
| It was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry Joanne Evans | |
| The CPS said it following the verdict it "will review its decision as a matter of course". | |
| A spokesman said: "The Crown Prosecution Service (CPS) considered this case very carefully indeed and concluded that a tragic mistake had occurred. | |
| "However, on reviewing the available facts, the CPS decided that there was insufficient evidence to offer a realistic prospect of conviction for gross negligence manslaughter." | |
| Dr Thomas 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". | 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. |
| Horror | Horror |
| 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. | 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. |
| 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 | 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. |
| 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' | '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. | 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. | "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. | "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. | "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." | "The verdict today confirms this." |