Failures by staff at Lincoln County Hospital to give insulin to a patient with diabetes caused or contributed to her death, an inquest has heard.
Janet Waterhouse died in the hospital on October 16, 2014, at the age of 73.
A two day inquest held at the Lincoln Cathedral Centre on January 21 and 22 concluded the omission of insulin by hospital staff on the days before Janet Waterhouse died was the cause or contributory factor to her death.
SPG Fisher, HM Senior Coroner for Central Lincolnshire, delivered a narrative verdict on the final day of the inquest.
He said that she had been hospitalised after a fall at her home in Sleaford on July 22, 2014.
She had initially been treated at Lincoln County Hospital but was transferred to Addenbrooke’s Hospital in Cambridge for an operation on a subdural haemotoma, a condition where blood collects between the skull and the surface of the brain.
Janet Waterhouse was transferred back to Lincoln County Hospital on August 22 but had been dependent on renal dialysis throughout her time in hospital.
She also required insulin to treat her diabetes.
The coroner said that failure to administer insulin on October 13 and 14 had caused a diabetic ketoacidosis.
Diabetic ketoacidosis is a condition caused by consistently high blood glucose levels. This happens when a severe lack of insulin means the body cannot use glucose for energy, and the body starts to break down other body tissue as an alternative energy source.
The inquest heard that disciplinary action was taken by United Lincolnshire Hospitals NHS Trust against those who had not monitored her, and that the trust issued advice to its staff on how to treat patients with diabetes.
Dr Jane Little, a consultant at Lincoln County Hospital gave evidence at the inquest, noting that long acting insulin should never be omitted to patients.
Dr Little added that her condition stabilised after insulin was restarted on October 14.
However, it deteriorated again later on that day after insulin was not administered and a clot formed on her fistula, meaning she was no longer able to receive dialysis.
A decision was made not to transfer her to hospital in Leicester and discussions were held with Janet’s family about her end of life care.
All treatment was withdrawn and Janet Waterhouse died on October 16, 2014.
In closing, the coroner expressed his deepest sympathies to the family.
He said: “It’s terribly tragic to lose a family member at any age but it’s even more tragic to do so if it was avoidable.”
Despite this, the coroner acknowledged that Janet Waterhouse was indeed a “very ill person.”