AN elderly diabetes sufferer who was discharged from hospital without her blood/sugar readings being checked was rushed back in a few hours later after an episode from which she never recovered.

A serious incident review carried out after the death of 80-year-old Pauline Gillott at the Maelor Hospital, Wrexham, found that was one of the failings and led to several improvements in processes.

At an inquest Joanne Lees, assistant coroner for North Wales East and Central, said although it could not be sure that her discharge had played a part in her death, the medication she had been prescribed in hospital had done so because, linked to her kidney failure, it had increased the chances of a hyperglycemic episode.

After recording a narrative conclusion Mrs Lees said she was satisfied, having heard of the steps taken by the Betsi Cadwaladr University Health Board in the wake of Mrs Gillott’s death, that there was no need to issue a Regulation 28 report to prevent future deaths.

“I am satisfied the issues I would have addressed in a report have already been addressed by the board,” she said.

Mrs Gillott, of Ash Grove, Mold, who was celiac and also suffered from heart disease, was admitted to the Maelor Hospital on July 8, 2017, suffering from vomiting and found to have a urinary tract infection.

Her condition improved and consultant Andrew Baker said she could be discharged on July 10.

Blood/sugar readings were asked for but arrangements were made for her discharge before the results were known.

Mr Baker told the Ruthin inquest it was unusual for readings not to be checked prior to discharge.

“There is no value to them if you are not going to pay any attention to the results,” he said.

While Mrs Gillott was waiting to be discharged she suffered another episode and so remained in hospital until the following day when she was again considered well enough to go home.

Sister Karen Morris said she was told she did not have to wait for the results and Mrs Gillott said she felt well enough to go home.

Her son took her home but at 2am the following day she was rushed back in after becoming unresponsive. Her condition deteriorated and she died on July 17.

Pathologist Dr Mark Atkinson gave the cause of death as hyperglycemic brain injury.

Dr Stuart Robertson, who examined the case after Mrs Gillott’s death, said she was suffering from kidney failure and the medication prescribed for her therefore increased the risk of hyperglycemic episodes.

It should therefore have been stopped.

“If the results had been checked it might have resulted in her being kept in hospital,” he said.

Pharmacist Karen Pritchard said procedures had been tightened, with more co-ordination between clinicians and pharmacists, and staff were being alerted to the risks in the use of such drugs for diabetic patients.

“We have highlighted the incident in junior doctor training,” she said.

Tracey Harris, who chaired the review panel, said one of the conclusions was that blood/sugar levels should be checked before discharge.

In her narrative conclusion the assistant coroner said she found as a fact that Mrs Gillott was discharged without the results being known, but she did not know whether it would have made any difference.

“But I do find on balance that the prescription contributed to her death,” she added.