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Inquest held after elderly woman died after insulin overdose and neglect

Betty Vaughan died at Good Hope Hospital, Birmingham in January 2009

Photo: istock

9 February 2011

The Coroner for Birmingham and Solihull Districts has held that an elderly diabetic woman died following an overdose of insulin, and neglect in her care, whilst an inpatient at the Good Hope Hospital, Birmingham.

Betty Vaughan was 80 years old when she was admitted to the Good Hope Hospital, and prior to her admission Betty was independent in all the activities of daily living.

She attended Accident & Emergency on 10 October 2008, but was sent home despite showing signs of a serious clinical infection.

She was then admitted as an inpatient the next day. On 15 October 2008, she was given her usual dose of insulin. Unfortunately, four hours later a nurse gave Betty a second insulin dose, by accident. This led to a severe hypoglycaemic episode and Betty was in a coma for the next five days.

After this event, the Coroner identified that there were further failures surrounding the standard of nursing care provided by the Good Hope Hospital to Betty, including the failure of the Hospital to properly assess Betty for falls. Sadly, Betty passed away at the Good Hope Hospital on 28 January 2009.

The Inquest was held before Mr Aiden Cotter, Coroner, and lasted four days. Mr Cotter delivered a narrative verdict and held that Mrs Betty Vaughan died following the insulin overdose and that neglect in her care also contributed to her death. He noted that whilst the insulin overdose was not the cause of death, it was a contributory factor. When delivering his verdict Mr Cotter also detailed further failures of the Hospital in this case that caused him concern, including the fact that Betty had numerous falls whilst at the Hospital.

Mr Cotter noted that there were some good nurses at the Hospital, but there were also a number of other nurses who needed to improve.  He will be writing to the Care Quality Commission, the independent regulator of health and social care, with his findings to express his concerns.

The family said:

"Hospital managers claim to have learnt lessons from previous errors however our mother's death exposes continuing concerns. We hope that this inquest will increase pressure on managers to make sure this never happens again."

Leigh Day & Co. represented the family at the Inquest, instructing Paula Sparks from Doughty Street.

For more information please contact Frances Swaine on 0207 650 1200.

Information was correct at time of publishing. See terms and conditions for further details.


Information was correct at time of publishing. See terms and conditions for further details.

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