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| Version 2 | Version 3 |
|---|---|
| Nurse's insulin overdose 'horror' | Nurse's insulin overdose 'horror' |
| (about 22 hours later) | |
| A newly-qualified community nurse gave an elderly diabetic patient 10 times too much insulin and she died about six hours later, an inquest has heard. | A newly-qualified community nurse gave an elderly diabetic patient 10 times too much insulin and she died about six hours later, an inquest has heard. |
| Joanne Evans told the Cardiff hearing of her horror when she realised her mistake in bed later the same night. | Joanne Evans told the Cardiff hearing of her horror when she realised her mistake in bed later the same night. |
| A diabetes specialist and a pathologist said it was likely the overdose had led to the death of Margaret Thomas, 85, of Pontnewynydd, Pontypool, south Wales. | A diabetes specialist and a pathologist said it was likely the overdose had led to the death of Margaret Thomas, 85, of Pontnewynydd, Pontypool, south Wales. |
| The inquest at Cardiff Coroner's Court is expected to last three days. | The inquest at Cardiff Coroner's Court is expected to last three days. |
| Giving evidence, Ms Evans said she was "in a tizz" when it struck her in bed that night that she had given Mrs Thomas too much insulin. | Giving evidence, Ms Evans said she was "in a tizz" when it struck her in bed that night that she had given Mrs Thomas too much insulin. |
| She said she immediately reported her mistake to a doctor but by that time Mrs Thomas had already died. | She said she immediately reported her mistake to a doctor but by that time Mrs Thomas had already died. |
| It was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry Community nurse Joanne Evans | It was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry Community nurse Joanne Evans |
| Ms Evans said: "I was thinking 'Oh my God if I've given her that much she's gone' and I couldn't believe it. | Ms Evans said: "I was thinking 'Oh my God if I've given her that much she's gone' and I couldn't believe it. |
| "It was very extreme circumstances and there was an error on my part and I'm really sorry, I will always be sorry." | "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. |
| 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. |
| Jammed | Jammed |
| Mrs Thomas was registered blind and could inject herself. | Mrs Thomas was registered blind and could inject herself. |
| Ms Evans said Mrs Thomas gave her an insulin "pen" which she had never used one 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 one before as they used a syringe and needle where she normally worked. |
| She told the court the first pen jammed so Mrs Thomas gave her a different one, which she had to assemble herself, and that too jammed. | She told the court the first pen jammed so Mrs Thomas gave her a different one, which she had to assemble herself, and that too jammed. |
| She said she was directed to the fridge where there was a different pen again - one she had used before, but that one was broken. | She said she was directed to the fridge where there was a different pen again - one she had used before, but that one was broken. |
| "Margaret kept on saying none of the nurses knew how the pens worked and were always having trouble with them." | "Margaret kept on saying none of the nurses knew how the pens worked and were always having trouble with them." |
| Ms Evans said she thought she had an insulin syringe in the car, but on fetching 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 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. | |
| Very independent | Very independent |
| "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. |
| She had administered hundreds of insulin injections in her nine months as a community nurse. | She had administered hundreds of insulin injections in her nine months as a community nurse. |
| Ms Evans said: "In hindsight, I think I should have turned to Margaret as soon as I entered the house and said 'I'm sorry I can't help you', and handed her over." | Ms Evans said: "In hindsight, I think I should have turned to Margaret as soon as I entered the house and said 'I'm sorry I can't help you', and handed her over." |
| Asked why she did not do that, Ms Evans 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. | Asked why she did not do that, Ms Evans 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. |
| "She was very independent and wanted to go out that afternoon and I wanted her to do that." | "She was very independent and wanted to go out that afternoon and I wanted her to do that." |
| Asked by Coroner Mary Hassell if it ever figured on her radar to ask for assistance, Ms Evans said: "I just kept thinking I was doing the best I could. Everybody was busy." | Asked by Coroner Mary Hassell if it ever figured on her radar to ask for assistance, Ms Evans said: "I just kept thinking I was doing the best I could. Everybody was busy." |
| The court heard that Mrs Thomas went out on a shopping trip with a friend that afternoon and that, at about 5pm, she became drowsy and stopped speaking. | The court heard that Mrs Thomas went out on a shopping trip with a friend that afternoon and that, at about 5pm, she became drowsy and stopped speaking. |
| When they returned home an hour later, Mrs Thomas collapsed and died on her doorstep. | When they returned home an hour later, Mrs Thomas collapsed and died on her doorstep. |
| Blood tests on Mrs Thomas suggested an insulin overdose, the court heard. | Blood tests on Mrs Thomas suggested an insulin overdose, the court heard. |
| Pathologist Stephen Leadbeater told the coroner that, if she accepted Mrs Thomas had been given 10 times too much insulin, he would find it difficult to say hypoglycaemia (low blood sugar) played no part in triggering a heart attack in a woman who already had furred-up arteries. | Pathologist Stephen Leadbeater told the coroner that, if she accepted Mrs Thomas had been given 10 times too much insulin, he would find it difficult to say hypoglycaemia (low blood sugar) played no part in triggering a heart attack in a woman who already had furred-up arteries. |
| But he added: "I can't say it's why she died. It's likely it played a part in her death." | But he added: "I can't say it's why she died. It's likely it played a part in her death." |
| Consultant diabetologist Dr Mark Evans said it was "probable" that hypoglycaemia had a significant role in Mrs Thomas's death. | Consultant diabetologist Dr Mark Evans said it was "probable" that hypoglycaemia had a significant role in Mrs Thomas's death. |
| The inquest was adjourned until Thursday. | The inquest was adjourned until Thursday. |