Nurse reprieved over collapse patient’s fatal insulin dose

Joanne Elizabeth Evans faced being struck off the nursing register after the death of Margaret Thomas, six hours after being given more than 10 times her usual dose of insulin.

Yesterday Mrs Evans was handed a one-year suspension by a medical panel which raised concerns over her competence in administering medicines.

Chairman John Matharu accepted there had been extenuating circumstances leading to Mrs Evans’ fatal mistake, but said a series of later errors while being placed under supervision highlighted the need to protect the public from further harm.

He said: “The panel has been deeply concerned by the registrant’s competence in administering drugs, as well as coping with stress. However, the panel reminded itself that this was an isolated incident that was not deliberate and there were significant extenuating circumstances.”

On June 2, 2007, Grade Four nurse Mrs Evans went to see Mrs Thomas after the pensioner collapsed on the doorstep of her home in Pontnewydd, Pontypool, following a shopping trip.

Mrs Evans tried to inject her patient with two insulin “pens” but both jammed. She then got a regular syringe from her car, not one usually used for insulin – which is measured in units, as opposed to millilitres.

She then wrongly converted the amount “in her head” and injected Mrs Thomas with four times the syringe with 3.6ml – approximately 360 units – instead of 36 units.

The panel heard Mrs Evans was under a great deal of stress, because of her daughter’s “serious illness” as well as severe staff shortages, resulting in her handling a workload usually undertaken by five people.

Mr Matharu also said she had been sleep-deprived following a dispute caused by the “anti-social behaviour of her neighbours”.

Following Mrs Thomas’s death, Mrs Evans continued to work for the Aneurin Bevan Health Board, formed in 2009 following the mergers of Gwent, Blaenau Gwent, Caerphilly, Newport, Torfaen and Monmouthshire health boards, under strict supervision – meaning she was not allowed to administer any drugs or medicines to patients on her own, as well as having to undergo additional training.