No remedial action taken 8 months after fatal insulin incident


Mrs Pauline Russell (61) died on 22nd November 2019 from aspiration pneumonia following her collapsing in a hypoglycemic coma. She had been injecting a higher incorrect dose of insulin since her discharge from hospital on 11th November 2019.


Whilst there were a number of contributory factors in the case the main issue was the fact that Mrs Russell and her husband were unable to read or write and therefore could not properly interpret the written instructions on the insulin that she was discharged from hospital with.


Norfolk area coroner, Yvonne Blake, raised concerns that there may be a risk of a similar incident happening again. More than that, Ms Blake was surprised to learn that at the time of the inquest both the discharging nurse and also the hospital had not made any changes in practice to mitigate the risk of people receiving medicines on discharge who were unable to read the instructions.


Mrs Russell, a poorly controlled diabetic, was admitted to the James Paget Hospital, Gorleston, Gt. Yarmouth on 6th November 2019 with a history of falls, and a urinary tract infection. She took amongst other things, insulin twice daily. Her insulin was increased to 64 units twice daily and she was discharged on 8th November 2019 on this regime.


Neither Mrs Russell nor her husband can read or write. Mrs Russell went home first, and her husband returned to the hospital to collect her medication. He was given a bag of medication and saw a letter inside. The staff nurse gave evidence that he went through Mrs Russell’s medications with her husband using the discharge letter as a reference. Mrs Russell told her husband when he returned home that the doctor had increased her insulin to 92 units twice daily. The dosage was queried, but she was adamant that is what she had been told. The correct dose to be given was listed on the discharge summary which neither could read. Mrs Russell received five days of 92 units of insulin twice daily. Mrs Russell injected the insulin herself.


On the morning of the 17th November 2019, a carer arrived. Mrs Russell was unresponsive and so she began resuscitation and called an ambulance. Mrs Russell was given glucose by paramedics which slightly improved her condition, but she did not wake up.


Life support was withdrawn, and Mrs Russell sadly died on 22nd November 2019.


The coroner, Ms Blake, raised a number of concerns as a result of the case. She said that no-one checked whether Mrs Russell could read. She commented that her admission pack has a long section on communication but not once is the question asked can you read or write or something of that nature. She continued that Mrs Russell would have been given menus to select from and been expected to read other things whilst in hospital, but nobody checked that she could do this.


She raised the fact that on discharge, no one checked that she could read and understand the discharge summary.


The area coroner for Norfolk Yvonne Blake commented:


“The inquest was eight months after Mrs Russells’ death and when I asked the nurse who discharged her about his current practice around patients being asked about literacy his reply was “I’m thinking about it” so even a death had not altered his practice.


“The hospital has not introduced anything during this long period of time to ascertain if their patients can read or write. I appreciate that it can be embarrassing to ask the staff and patient, but it is vital that if people are being discharged home with written instructions, they can read them to check those instructions, or be shown in a different way what the instructions are, eg. a diagram, getting a relative to read them or a carer.


“I find it surprising that nothing has been done on the hospital’s own initiative in eight months and I remain concerned that a similar incident may occur again.”


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