“In December 2022 Mr Hurwood was an in-patient at Northampton General Hospital”

The coroner’s concerns

– In December 2022 Mr Hurwood was an in-patient at Northampton General Hospital. This followed a fall at home. During this admission he suffered multiple episodes of hypoglycaemia. Mr Hurwood’s insulin medication was to be provided by nurses within the hospital. I have heard evidence from a Diabetes Specialist Nurse at the Diabetes Centre at Northampton General Hospital that on 12 December 2022 Mr Hurwood was referred by ward staff for a diabetes review. The Diabetes Specialist Nurse explained in evidence that she observed that nurses (plural) were administering Mr Hurwood’s insulin after meals. She advised the nurses that Mr Hurwood’s insulin should be provided before his meals. In evidence, the Diabetes Specialist Nurse told me: a. Insulin should be administered prior eating. b. Its effectiveness is reduced if not administered before eating. c. This was not the only time that she was aware that nurses at Northampton General Hospital were (incorrectly) administering insulin to patients after they had eaten their meals. d. This continues to happen “occasionally”: the most recent episode which she had directly encountered occurred in the last 2 to 3 months. e. Whilst the Diabetes Centre members have had discussions with nurses and training does occur “the message does get through for some people”. The 1 implication – which she agreed was the correct implication – was that the “message” did not get through to other nurses. A former Ward Sister at Northampton General Hospital has also given evidence at the inquest. She agreed that staff must get insulin administration correct. She thought the incorrect administration of insulin after a meal “probably does happen”. She accepted that there was “no excuse” for this, but pointed to the possible contributory effect of a lack of staff.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0078

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0