Coroner Describes Actions Of Nurse As ‘Gross Failure To Provide Basic Medical Treatment’

The heartbroken family of a diabetic woman whose life could have been saved if medics had carried out a simple blood test have today spoken of their anger after an inquest heard that a catalogue of nursing failings contributed to her tragic death.

Mother-of-three Margaret Pitt from Redditch, had a long history of ‘type one’ diabetes, but suffered an irreversible brain injury and died on 21 November 2010, aged 55, after medical staff at the Alexander Hospital failed to implement a thorough care plan that would have seen her glucose levels monitored and acted upon accordingly.

Following today’s narrative verdict, medical law experts at Irwin Mitchell representing the family said they are considering a referral to the Nursing and Midwifery council, the authority responsible for nursing standards, to investigate the conduct of those responsible for Margaret’s care.

During a five-day hearing, HM Deputy Coroner for Worcestershire, Marguerite Elcock, heard how an experienced nurse failed to carry out blood tests which would have shown that Margaret’s glucose levels were not being controlled after she was admitted. During her summing up the Deputy Coroner described the actions of this nurse as a ‘gross failure to provide basic medical treatment’.

Sara Burns, a Partner and medical law expert at Irwin Mitchell’s Birmingham office representing the family, said: “The inquest has been incredibly harrowing for Margaret’s family as they have heard that she was woefully let down by a number of clinicians on this ward.

“Repeated opportunities to intervene and stabilise Margaret were missed and guidelines for blood glucose level testing were not followed to manage her diabetes. NHS policies and guides are in place for a reason – to save lives, and staff across the NHS must follow these to prevent unnecessary deaths.

“We will continue to help Margaret’s family in their battle for justice and we are now considering whether, given the evidence heard during this inquest, it is appropriate for us to refer the case to the Nursing and Midwifery Council.”

Margaret had lived with ‘type one’ diabetes for more than 30 years, having been diagnosed when she was 20 years old. The former teaching assistant was insulin dependent and over the years had become used to the daily routine of injections and checking her blood glucose levels.

However, on 4 November 2010 Margaret began to feel unwell and she recognised the tell-tale signs that her blood glucose levels had risen to a point where she needed medical help. She was admitted to the Alexandra Hospital and after being treated in intensive care she was moved to a ward for ongoing glucose tests and treatment.

In the early hours of 13 November, Margaret was found collapsed and unconscious and she was rushed back to intensive care where doctors discovered that she had suffered severe brain damage as a result of dangerously low blood glucose levels (hypoglycaemia).

Margaret’s family were told that the damage was irreversible and there was nothing more that could be done. She remained in intensive care until she was transferred to Primrose Hospice on 19 November where two days later, she died.

Husband, David, said: “Maggie and I had been happily married for 35 years and for her life to be tragically cut short so needlessly is almost too much to bear.

“I am absolutely distraught by Margaret’s death and very angry that she was let down so badly by the nurses that she put her complete trust in.

“My wife deserved far better. She was on a ward which was supposed to have experience of caring for diabetic patients and supposedly had the expertise to treat her condition, yet it appears she was just left to deteriorate without anyone checking her blood sugar levels.

“Over the years there were a number of occasions when I had to pull Maggie out of hypoglycaemic shock. I would check the back of her neck and if she was perspiring, I would give her warm water and a glucose tablet. It’s not rocket science and so I still don’t understand how trained medical staff got it so wrong.

“I believe she would still be alive today if she had received the correct treatment and, although nothing will turn back the clock for us, I hope improvements have since been made to protect any other family from suffering the heartbreak we have had to endure.”

Margaret’s daughter, Samantha, added: “Margaret or ‘Maggie’ as she was affectionately known, was a loving mother, grandmother, sister and daughter. Her unexpected death has left a very large void in all our lives. Due to a series of failures she is now unable to watch her children and grandchildren grow up and have been stripped of the chance to happily live out her retirement in her beloved chosen location of Somerset for which she had so many plans.

“We are grateful that the inquest has provided us with some important answers regarding the circumstances of my Mum’s death, so that we as a family can have some closure after 19 long and very hard months but we will continue to battle for justice to ensure no one else is let down like she was."