Mr Leslie Hurwood · Prevention of Future Deaths report

On 18 January 2023 an investigation was commenced into the death of Mr Leslie Hurwood. On 5 February 2025 the inquest hearing began and is due to conclude tomorrow (6 February 2025).

Mr Hurwood died on 13 January 2023 at Kettering General Hospital. He had a history of Type I diabetes mellitus (from 1969), hyperlipidaemia, hypothyroidism, glaucoma and essential hypertension. He had recently been diagnosed with dementia. Until 2022 his diabetes was well-managed.

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 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.