A diabetic father died after being administered syringes that contained no insulin due to a manufacturing error, an inquest has heard. Neil Judge, 58, a club steward, became the victim of 'human error' after Sheffield Teaching Hospitals received a batch of pre-filled syringes that only contained saline solution instead of the required mixture of saline and insulin.
Mr Judge was left without insulin for nearly 14 hours, leading to an episode of diabetic ketoacidosis. Two days later, on November 22, 2010, he died of multi-organ failure. Coroner Chris Dorries ruled that the medicinal failure was a 'major contributory factor' in his death.
The inquest at Sheffield heard that the faulty batch was supplied by Fresenius Kabi Ltd, based in Runcorn, Cheshire. Christopher Harrison, the company's executive vice-president, said the mistake occurred over a shift change and that there had been no batch testing of the syringes. Fresenius Kabi stopped producing the drug after Mr Judge's death.
It also emerged that a similar faulty batch had been sent to hospitals in Scunthorpe and Kettering a month earlier, but the company treated it as an 'isolated' incident. Police investigated possible corporate manslaughter but no charges were brought. Mr Judge's wife Linda is now taking legal action against the company.
The coroner said he would write to the Department of Health to address a 'loophole' allowing unlicensed 'specials' to be supplied without proper checks. The Medicines and Healthcare Products Regulatory Agency typically licenses medicines, but unlicensed products can be legitimately supplied on a 'specials' basis.
