Regulation 28: Prevention of Future Deaths report – Susan Warby

Summary

Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. 

This is a coroner's report into the death of Susan Warby.

The coroner's report concluded that the incorrect intravenous fluid was given and remained in place for approximately 36 hours before it was changed. As a direct result, blood tests on samples drawn from the arterial line gave incorrect results. The incorrect results were exacerbated by the poor technique being used by staff to draw blood from the arterial line transducer set when they failed to fully account for the 'dead space', which needed to be fully removed to obtain an accurate result.

These erroneous blood results led to Sue being given doses of insulin medication over a two-day period that she did not need. The incorrect insulin doses caused Sue to suffer from bouts of extremely low blood sugar (hypoglycaemia) which caused her to develop a brain injury of uncertain severity.

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