Diabetic died after receiving ten times normal drug dosage

Published on 16/11/2005 01:17

A WOMAN died after being injected with an overdose of insulin ten times the amount prescribed for her by a hospital doctor.

Yesterday a fatal accident inquiry heard that Moira Pullar, 62, suffered a heart attack and died five days after she was administered 40 units of insulin instead of four at Airdrie's Monklands Hospital.

The doctor who wrote the prescription told Airdrie Sheriff Court that her writing had been altered so that a letter u, which signified "units", written alongside the number 4, looked like an "a" or an "o" so the dosage then appeared to read "40".

The court heard Mrs Pullar was not given the fatal dose until ten hours after the doctor had written the prescription.

The court heard from Dr Tobias Hatta, a pathologist at Glasgow University, who carried out the postmortem examination on Mrs Pullar on 22 January, 2004.

He told the inquiry: "The cause of death was bronchial pneumonia, hypoxic brain damage and a cardiac and aspiratory arrest, brought on by excess insulin. I am told she had a history of diabetes and high blood pressure and that the day before she suffered a cardiac arrest she had been given 40 units of insulin, when it should have been four units. This amount is an equivalent to an overdose. It was excessive and inappropriate."

Mrs Pullar, of Airdrie, who had three daughters and a son, was admitted to Monklands Hospital on 8 January, 2004, from nearby Carrickstone Nursing Home, where she was a resident. Her daughter, Natalie Martin, said: "When I went to see her along with my sister Laura on the Saturday she was happy, laughing and joking, although she was completely reliant on staff for her general care.

"When we went back on the Sunday morning, we got a fright. She was just lying there, not moving. She looked terrible. We thought she was dead."

Ms Martin went to the nursing station to say that she thought her mother had died. She told the inquiry: "The nurses came back with the crash team in an attempt to resuscitate my mother. They did this and then took her for a brain scan.

"On the Monday we were told she had been given an excessive dose of insulin." Mrs Pullar never regained consciousness and died on 17 January.

Dr Sarah Drury, 26, a senior house officer at Monklands Hospital, examined Mrs Pullar on arrival and told the court that she had written on her notes for her to be given 4u (units) of insulin, but that her writing appeared to have been altered.

Asked by the fiscal-depute Janice Green if she knew who had changed the dosage, the doctor replied: "No." Dr Drury told the inquiry that it had been a very busy day for admissions,

but she did not know why the insulin was not given to Mrs Pullar until ten hours after the prescription was written.

When Mrs Pullar was admitted to ward 14 of the hospital, she was cared for by a team of lower grade nurses, with no senior nurse on duty.

One of the nurses on duty at the time, Linsey Walker, 23, told the inquiry: "For some reason I didn't check her notes and didn't realise she was a diabetic."

After Mrs Pullar's death an internal inquiry was headed by Elspeth Ritchie, a registered nurse. She told the inquiry: "Procedures being adopted at the time were not normal procedures. There has been a full review and this has led to several changes."

The inquiry, before Sheriff Robert Dickson, is expected to conclude today.