A director of the organisation which runs Bradford Royal Infirmary has apologised for “significant failings” during its care of an elderly woman who was “passed from pillar to post” before dying a few days later.

Chief Nurse Juliette Greenwood was not working at the Trust when Sheila Hibbert died in February, 2012, but was present at the two-day inquest into the 77-year-old’s death.

Yesterday, she told Bradford Coroner’s Court it had raised issues that had “very clearly been learnt from”.

Addressing Mrs Hibbert’s son, Julian, and his wife she said: “There were significant failings to Mrs Hibbert and yourselves in the care provided. There is nothing we can do to change that and I personally, as a nurse and as the chief nurse, apologise for that.”

She said many assumptions were made during Mrs Hibbert’s care when she was admitted to Ward 15 on January 30, 2012, after being sick and that “she was passed from pillar to post and fell through a number of gaps”.

Mrs Hibbert was diagnosed with Type One diabetes in her 40s and had daily visits from district nurses who administered insulin, but the district nursing team was not told when Mrs Hibbert returned home from hospital on January 30.

They did not find out until the Thursday when a nurse rushed to Mrs Hibbert’s home in Ashfield Court, Bingley, and found her unwell in bed. She was taken to BRI by ambulance, where she died on February 6.

A post mortem examination found the cause of death was multiple organ failure and signs of diabetic ketoacidosis which can happen when a lack of insulin means the body cannot use glucose for energy and starts to break down body tissue.

The inquest heard from several of the nurses and doctors involved in Mrs Hibbert’s care. It emerged that many assumptions about who was responsible for aspects of that care had been made.

Rose Mary Smith assessed Mrs Hibbert at 10pm on January 30, composed an action plan for her care and asked for her to be hydrated.

She told the inquest that she asked for Mrs Hibbert’s blood sugar levels to be checked four times a day and, as the patient did not have her insulin with her, that arrangements were made the following morning to find out the type and dosage of insulin required.

“At the time, we didn’t know what type of insulin she took or what dose, so it would be dangerous to prescribe any type for her, so she’d need her daily insulin which she took,” Dr Smith said, adding that she had no reason to doubt that would be done.

The doctor said there was no need to start a ‘sliding scale of insulin’ as Mrs Hibbert seemed well at 6am the following morning, despite a high blood sugar reading.

“If it was exactly the same today, I’d have done exactly the same, but there would be processes in place for a formal handover,” she said.

Miss Greenwood said she hoped the family could see how much Mrs Hibbert’s death had affected staff on the ward.

Coroner Dominic Bell’s conclusion of the case is expected on Friday or Monday.