Sherwood Forest Hospital Trust carries out full investigation into failures at Newark and King's Mill hospitals that contributed to Upton grandmother's death

In her conclusion, after hearing two days of evidence, assistant coroner Dr Elizabeth Didcock said a series of failures and neglect led to Marie Henson’s death.

She said: “I am clear that the failures on February 3, February 5, and February 6, 2019, have a clear and direct causal link to Marie’s death. But for the lack of insulin treatment Marie would, on the balance of probability, have survived.”

She said the lack of recognition of diabetes at Newark Hospital was a gross failure.

She accepted that although the GP at Southwell should have looked for type one diabetes or DKA, it did not constitute a gross failure to provide basic medical care.

She said Dr Heer had reflected on the care that he provided, as had the nurses involved, and they had learnt from their mistakes.

At King’s Mill Hospital, Dr Didcock said: “The lack of delivery of insulin, and that this was not discovered for nearly three hours, is also in my mind a failure to make a simple basic check.

“I have identified at least four missed opportunities to provide insulin treatment ­— a basic medication for a common condition. Overall, I am satisfied that neglect contributed to Marie’s death.”

Dr Didcock said the trust commissioned a serious incident investigation report, which was converted into a detailed action plan, and training had been carried out.

Dr Didcock described Dr Palissery’s evidence as muddled and inconsistent.

She said: “I did not find his evidence convincing nor sufficient in relation to his learning following Marie’s death. I ask that the responsible officer at the trust (Sherwood Forest Hospitals) to review his current competencies and ability to work without consultant supervision at Newark Urgent Care Centre.

“If there remain concerns then, as would be usual, I would expect Dr Palissery to be referred to the General Medical Council for further assessment of his fitness to practice.”

The trust has provided four weeks of additional supervised training for him and he is rotated to work in the King’s Mill Hospital emergency department where he can develop expertise with more ill patients and have direct access to a consultant on site.

“This higher level of support is not, however, available when he and other middle grade doctors are working at Newark Hospital without direct consultant supervision,” said the coroner.

Read more of the inquest here:

Coroner calls for investigation into Newark's urgent care centre after death of grandmother

Inquest highlights missed chances to save patient

'We were betrayed by the people who were supposed to help her'