Four key errors by staff at Bradford Royal Infirmary led to the death of an elderly patient, a coroner has ruled Grandmother Sheila Hibbert, 77, of Bingley, died at the hospital last year following the series of failings in her care, an inquest heard yesterday.

Mrs Hibbert has been taken to BRI at 9pm on January 30, 2012, having been sick and feeling nauseous.

She was diabetic and received insulin during daily visits from district nurses. She was also undergoing chemotherapy for endometrial cancer and in the month leading to her death, blood tests showed her renal function was deteriorating.

Recording a narrative verdict yesterday, Bradford Assistant Coroner Dominic Bell said despite her long-term diagnosis as diabetic – a condition which needs “diligent” care – medical staff failed to carry out blood tests when she was admitted.

Her diabetes was identified and a care plan drawn up, but instructions to check her prescription were not followed up and her blood sugar levels were not checked until 6am.

Dr Bell said a “series of assumptions” from nurses and doctors contributed to Mrs Hibbert not receiving her medication.

On January 31, Mrs Hibbert was given her planned chemotherapy and discharged – but the hospital failed to let district nurses know and so no-one visited her home in Ashfield Court, Bingley, on February 1 to administer her insulin.

On February 2, district nurses were made aware that Mrs Hibbert was back at home and one immediately went to see her. Mrs Hibbert was unwell, her blood glucose levels were high and an ambulance took her back to BRI. Mrs Hibbert was diagnosed with diabetic ketoacidosis – a dangerous complication caused by a lack of insulin – and died on February 6 last year.

Dr Bell said: “During her admission there was, one, a failure to identify the origins of her admission symptoms. Two, a failure to identify her deteriorating renal function. Three, a failure to prescribe and administer the appropriate insulin and four, failure at the point of discharge to notify the district nursing team.”

Following the hearing, Mrs Hibbert’s son Julian, 50, who is pursuing legal action against the Bradford Teaching Hospitals NHS Foundation Trust, said he was “shocked and appalled” at some of the evidence.

“It seems there was a complete breakdown – nobody seemed to be doing what was expected, and nobody seemed to be taking responsibility,” he said.

Mr Hibbert said the inquest had been more detailed than he expected and Dr Bell had left no stone unturned. “It seems there have been a lot more mistakes made than we initially thought – mistakes all the way through,” he said.

A spokesman at the Trust said after the hearing: “We would like to pass on our sincere and heartfelt condolences to Mrs Hibbert’s family.

“The Foundation Trust has taken Mrs Hibbert’s death extremely seriously and we acknowledge that the care provided to Mrs Hibbert fell below acceptable standards.

“The Foundation Trust took immediate action to investigate the circumstances surrounding this sad loss of life and took swift action to ensure that lessons were learned by all staff and that lasting improvements to clinical care were made.

“The Foundation Trust accepts fully the findings of the inquest and recognises that there are additional lessons to be learned for all medical and nursing staff. The Foundation Trust will act upon the findings as a matter of urgency.”

Dr Bell said he was satisfied with procedural changes made following an investigation at BRI and assured by apologies made by various Trust staff.

Mr Hibbert, of Eastmoor, Wakefield, said: “The new measures seem to be very good, but they’re too late for us.”

“My mum was a very quiet person, but one of the main reasons we got so involved was that she would have been appalled if she’d read about it happening to someone else.

“She would have thought it important and she would have wanted to do something about it.”