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Nurse blunder led to huge insulin overdose

A diabetic pensioner who died from broncho-pneumonia was given an insulin overdose by accident two months before his death, it has been revealed
An inquest into the death of Henry Hill, from Lesbury, Northumberland, found that the 86-year-old received a dose of insulin that was ten times stronger than it should have been. The mistake was made by a district nurse, who used a standard 1ml syringe instead of a specialist insulin syringe.
Mr Hill, who was on an “unusual” once-daily insulin regimen, was quickly taken to hospital but was discharged the following day after appearing not to have suffered any ill-effects from the overdose.
However, two months later the retired engineer was found unconscious at his home and died in hospital just two days later, in March 2009, from broncho-pneumonia.
While a post-mortem concluded that his diabetes might have caused Mr Hill to collapse, medical experts ruled that the insulin overdose did not contribute to his death.
This view was shared by consultant physician Dr John McKnight, the lead clinician for diabetes in Scotland, who was asked by north Northumberland coroner Tony Brown to produce an independent report for the inquest.
However, Dr McKnight did conclude that low blood sugar (hypoglycemia) was the most likely explanation for Mr Hill’s final illness and death, adding to concerns from the pensioner’s family about the way his blood glucose levels were monitored and managed by NHS staff.
In his final verdict, Mr Brown told the inquest yesterday that Mr Hill’s broncho-pneumonia was probably the result of a hypoglycemic episode, caused by poor control of his diabetes, and described the accidental overdose as a “serious failure of care”.
Mr Hill’s son Bob, 60, said: “I’m pleased at the mention of poorly-controlled diabetes within the verdict because, in my view, the overdose was the beginning of a catalogue of errors that nobody in the service picked up for two months.”

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