Woman died after Good Hope Hospital insulin overdose

A double dose of insulin given to a grandmother in hospital contributed to her death, an inquest has heard.

Betty Vaughan, 80, of Sutton Coldfield, died in January 2009 of pneumonia, ecoli and MRSA, her family said. She also had many other infections.

An inquest heard she did not recover from the insulin overdose administered at Good Hope Hospital in Sutton Coldfield in October 2008.

The inquest at Birmingham Coroner's Court is expected to last four days.

Coroner Aidan Cotter heard that before going into hospital, Mrs Vaughan had been well enough to arrange her own birthday party and look after her elder sister.

She first went to Good Hope on 10 October, 2008, but was sent home.

'Brain damaged'

That night she fell out of bed, was unable to walk and was readmitted to hospital with septicaemia.

A review of her treatment found she should not have been sent home, the inquest was told.

On 15 October Mrs Vaughan, a diabetic, was allowed to inject herself with insulin in the presence of a nurse who wrote it in the notes.

According to a report by the Heart of England Trust, Mrs Vaughan later that evening told another nurse that she had not had her insulin.

She was given the injector pen but the nurse was called away, and did not see her inject herself.

Former medical director Hugh Raynor said an over reliance on the patient, rather than her health chart, had been responsible for the error.

He added that the second insulin dose did not appear in the notes and the patient should have been monitored after the injection.

Mrs Vaughan survived the overdose but her daughter-in-law Stephanie Vaughan, a former hospital ward sister, went to Birmingham Social Services on 20 October to complain about the treatment.

"She never fully recovered from the insulin overdose," she said.

Pathologist Peter Ackland told the inquiry the overdose had left her brain damaged and was likely to have contributed to the death.

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