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Diabetic patient unlawfully killed after lethal insulin injection from community nurse


A diabetic patient who was given a lethal dose of insulin by a community nurse was unlawfully killed, a coroner has ruled.

Newly-qualified community nurse Joanne Evans now faces multiple inquiries after the decision today at an inquest in Cardiff.

Her employer, Gwent Healthcare NHS Trust, said Ms Evans is not working at the moment because of an internal disciplinary procedure.

However the trust could not give further information as her case has been referred to the Nursing and Midwifery Council.

The Crown Prosecution Service (CPS) has also said that it would review the case after the verdict.

A CPS spokesperson 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.

‘The CPS has explained the decision to the victim’s family and now a verdict of unlawful killing has been returned, the CPS will review its decision as a matter of course. Our thoughts remain with the victim’s family at this time.’

The inquest heard that Ms Evans injected Margaret Thomas, 85, with 10 times the correct dose of insulin.

She miscalculated the dose because she used a conventional syringe instead of an insulin pen, the court heard.

Ms Thomas, who was registered blind and could not self-administer insulin, collapsed and died six hours after the injection, the court heard.

Basic nurse training instructs them to always use special insulin syringes because insulin is measured in units, not millilitres.

Ms Evans apologised about her mistake at the inquest. However her son, Dr Hywel Thomas, said: ‘It is apparent that there were failings in her training and clinical judgment to request further assistance. The verdict today confirms this.’


Readers' comments (7)

  • I truly believe that in a lot of cases, training and mentoring is lacking. I have seen many student nurses try to avoid doing any practical work saying they are supernumery. The article does not say how newly qaulified Ms Evans was at the time, but by the mere mention that she WAS newly qualified, should there not have been an experienced staff nurse there to check what Ms Evans was administering unter the mentorship programme?

    I worked recently with a young nurse who had only worked as a district nurse for 2 years post grad, she came to work with us on a medical surgical unit and it was extremely evident she lacked basic nursing skills and especially pharmacology knowledge. Unfortunately this girl had to be "let go" and the same happened at the next hospital she worked, she now works nights in a nursing home. This shows in my mind, a lack in training somewhere along the line.

    The nursing educators are putting patients lives at risk and letting our student and newly qualified nurses down.

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  • Once again someone has to have a dig at the educators for the deficiencies of some newly qualified nurses. As 50% of pre-registration courses are spent in clinical practice might it not just be the case that the mentors have failed to develop the students' clinical competence? Students go to placements to learn under experienced nurses; if mentors allow them to avoid essential practice on the grounds that students are supernumerary then they fail to understand the concept & are failing in their duty to train students.

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  • Well said Ian

    The only other fact I would highlight is that practical competence is assessed and passed/failed by mentors in practice settings, NOT the much maligned Universities.

    Having said that, it is unfortunate fact that catastrophic errors can and do happen to a number of our colleagues - experienced, newly qualified, the expert and the less competent. Very rarely can the blame be squarley laid at the feet of just one individual and I'm sure I'm not alone in feeling sympathy for the nurse in this dreadful situation as well as for the bereaved family.

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  • I too have great sympathy for the family and also for the poor nurse who had entered a career in the hope of helping people and then accidently for one reason or another has ended up with a tragic incident that will live with her for the rest of her life.

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  • Yes, a sad story for all concerned. I wonder why the nurse didn't have the right equipment.

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  • There appears to be a lot of blame put at the feet of the educators and training. (Believe me i am not always a fan of current nurse training)But as qualified nurses we abide by the NMC code of conduct and so should not carry out duties we are not competant to do. There was a catalogue of errors and the nurse should have asked for help. All district nurses carry phones don't they?

    There is error on all sides. unfortunately this was an horrendous way to learn lessons

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  • Nursing school.... my teachers not sure whether some had PHD's, some had MA's etc? We referred to them as facilitators rather than teachers.
    I remember nurse training to be more like boot camp,..... I heard my nurse mentor say... "I had to be tough with you".... All I thought about was , the day my training would end.... I can't remember a day without suffering emotionally in one way or another. But I do think suffering wises you up in one way or another. I have always been a sensitive person and am proud to say it, because it has allowed me to be as empathetic with my patients as I am with my family. And if I had "toughened up" as my supervisor suggested, I wouldn't be the caring nurse that I am today.

    This is a tragic story and feel sad for both parties.
    I also care about the new nurses and believe there should always be a mentor period after graduation. It can be the scariest thing if there is little support. If Doctors have this opportunity why don't nurses?

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