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| Insulin OAP was unlawfully killed | Insulin OAP was unlawfully killed |
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| 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. | |
| 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 inquest heard Joanne Evans had used the wrong type of syringe | |
| 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. | |
| 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. | |
| 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. | |
| 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. | |
| 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. |