The son of an elderly woman who died following a stay in Bradford Royal Infirmary believes mistakes made by hospital staff could have cost his mother’s life.

An inquest into the death of 77-year-old Sheila Hibbert heard a statement from her son, Julian, which outlined events leading to her death in February 2012.

The statement said Mr Hibbert believed his mother might not have died “if people on Ward 15 had done what they should have done and checked her notes”.

District nurses who visited Mrs Hibbert daily to administer insulin to control her diabetes were not made aware that she had returned home from hospital and so missed a visit.

Bradford Coroner Dominic Bell said Mr Hibbert had raised concerns before the inquest that Bradford Teaching Hospitals NHS Foundation Trust was taking responsibility, when individual staff members were to blame.

But Dr Bell said it was important not to “browbeat” witnesses.

“If we concentrate on individual blame, then it’s unlikely that we will be able to identify the need for system change,” he said.

Yesterday the court heard that Mrs Hibbert, who lived alone in Ashfield Court, Bingley, died on February 6, 2012, from multiple organ failure. She had been receiving chemotherapy treatment after being diagnosed with endometrial cancer in October 2011 and having a full hysterectomy two weeks after the diagnosis.

On the evening of January 30, 2012, Mrs Hibbert was with her son and daughter-in-law and feeling unwell. She had been very sick and her daughter-in-law called the oncology Ward 15 of Bradford Royal Infirmary.

She was advised to take Mrs Hibbert to the hospital if her condition did not improve in an hour, was taken in at 8.30pm and seen by a doctor at 10pm.

Mrs Hibbert was kept in hospital overnight where she was already due to undergo chemotherapy the following day.

The inquest heard that Mrs Hibbert, who had suffered a heart attack in 2008, had received insulin injections for her diabetes, given by a district nurse, each morning since 1991.

Mrs Hibbert was discharged from hospital on January 31, but district nurse Laila Bretts, of Westcliffe Medical Centre in Shipley, said she was not aware her patient was back home until February 2, when she received a call from staff at Ward 15.

Care workers had found Mrs Hibbert was ill at home and called the hospital, then called Mr Hibbert and asked him to call BRI as staff could not discuss her condition with non-relatives. Hospital staff then called the district nursing team at about 9am.

Nurse Bretts told the inquest: “We kind of got a bit worried thinking that as far as we knew she wasn’t at home. Then they told us she had actually been discharged on the Tuesday, at which point I picked up my coat and bag and set off. I realised then she hadn’t been seen on Wednesday to have her insulin.”

Mrs Hibbert’s blood sugar levels were high and she was given her insulin injection, but she did not improve. An ambulance was called which took her back to BRI where she died on February 6.

The inquest heard that since Mrs Hibbert’s death changes had been made at the hospital ward, which include having electronic records of triage calls – when patients call hospital for advice – and an electronic, more thorough, handover and discharge system.

Hospital administration forms now also include a specific question about diabetes.

There are now also ward rounds where staff from several departments visit patients to discuss their care.

The hearing continues.