Bertram Theophilus HAMILTON · Prevention of Future Deaths report

On 23rd March 2011 I commenced an investigation into the death of Bertram Theophilus HAMILTON of Mansby House, Ryland View Nursing Home, Arnhem Way, Tipton, West Midlands. The investigation concluded at the end of the inquest on 21st February 2014. The conclusion of the inquest was that death was due to Natural Causes.

Mr. Hamilton had been a long term resident in a care home. On the morning of his death, his blood sugar was checked because he was diabetic and was found to be 1.6, but despite this an injection of insulin was given by a nurse ████████ Although Mr. Hamilton died shortly afterwards, the expert evidence was to the effect that the insulin probably did little harm in the context of Mr. Hamilton’s then existing condition.

I am concerned that the nurse in question appeared not to know that insulin should not be given to a person whose blood sugars were so low. In addition, I was concerned that the nurse was not frank and open in giving evidence to me and claimed that she had given Mr. Hamilton a sugary solution, that she had re-checked his blood sugar and gave the insulin only after the blood sugar level was high. None of the contemporaneous documentation, including documentation completed by the nurse herself, supported such a contention.