Conor Dufficy was instructed in the inquest that concerned the death of Susan Warby.  Earlier this year, her story received national press coverage, because of an anonymous letter from a purported member of staff to Susan’s husband and subsequent allegations of a witch-hunt by the West Suffolk NHS Foundation Trust for a whistleblower.  The inquest concluded on 7 September 2020 after and adjournment for evidence from an expert in Intensive care.  Mr Parsley, the Senior Coroner for Suffolk, delivering a narrative conclusion,  found that Susan died as the result of the progression of a naturally occurring illness (a perforated diverticulum leading to peritonitis), and this was contributed to by unnecessary insulin treatment caused by erroneous blood test results.  The erroneous results occurred because of the administration of dextrose solution via an arterial line at the time of her original operation (instead of a saline solution).  This was compounded by bad technique in removing ‘dead space’ from blood samples taken from the arterial line.  The blood samples showed very elevated levels of blood glucose (hyperglycaemia), which was erroneous.  This led to the administration of insulin and then to hypoglycaemia (very low levels of blood glucose), causing a degree of brain injury which contributed to her death.

The Senior Coroner sent a prevention of future deaths report to Matthew Hancock, the Secretary of State for Health & Social Care, and to the MHRA.

The case has been reported by The Guardian and can be viewed here.


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