Cardiff and Vale University Health Board has responded to an inquest that found multiple failings in the care of a beloved father who died after being mistakenly injected with insulin at the University Hospital of Wales in Cardiff.
Health Board Statement
A spokesman for the health board said: 'Our thoughts remain with Mr Gough’s family and loved ones at this incredibly sad time. We would like to thank the coroner for the careful consideration of the facts throughout the inquest and fully acknowledge the narrative conclusion.'
'The health board is committed to learning and improving. We openly accepted at the outset of the inquest the failings identified in this very sad case. The health board would welcome the opportunity to meet with the family to further discuss the steps outlined in the inquest that the organisation has taken immediately following and in the years since this tragic event.'
The Inquest Findings
Donald Gough, 77, a bowel cancer patient, had agreed to surgery to remove secondary tumours from his liver, which carried a mortality risk of 5% or lower. However, he never woke up from the procedure after being mistakenly injected with insulin, despite not being diabetic. He slipped into a coma and died a month later in intensive care.
The two-week inquest at Pontypridd Coroners' Court heard that there was no clinical reason for medics to administer insulin during liver surgery. Coroner David Regan concluded that Mr Gough's death was caused by a failure of care by health staff who most likely wrongly injected him with insulin instead of local anaesthetic at the end of his surgery, combined with the failure of several doctors to act on signals showing something was wrong.
No Malicious Intent
A police investigation was launched after unexplained high levels of insulin were found in his body, but no criminal charges were brought. The inquest, which concluded on June 12, found that while errors occurred, no clinicians or others acted with malicious intent. Mr Gough was a former NHS radiographer.
Coroner Mr Regan told Mr Gough's grieving family: 'Systems based on human checks may unaccountably break down.' He concluded that no-one intended to kill Mr Gough, and there were failings of care but not neglect of care.
Family's Response
In a statement after the inquest, Mr Gough's family said his death was a huge loss but he would never be forgotten. They described him as a man known for his warmth, loyalty, and kindness.
Mr Gough, born in west Wales, worked as a superintendent radiographer at Glangwili Hospital in Carmarthen. The coroner stated that Mr Gough would have survived if the multiple failings had not occurred.
