Diabetic Yorkshire aristocrat died after being prescribed too much insulin in hospital

Simon Howard, scion of the aristocratic Howard family, which has lived at Castle Howard, near York, for 300 years, died after being given too much insulin while being treated in York Hospital, an inquest has ruled.

Younger son of the late Baron Henderskelfe, Simon Bartholomew Geoffrey Howard, 66, ran the stately home and estate after his father’s death in the early 1980s until 2015, when his brother Nicholas took over and he moved to nearby Welham Hall.

Mr Howard was found at home by his son, Merlin, in February 2020, after falling down the stairs. He was conscious, but struggled to speak. A neurosurgeon who examined him in hospital believed he might have been intoxicated. He was found to have fractured his skull and suffered permanent brain damage, but he did not require surgery and returned home.

Mr Howard, who was married with twin children, had been diagnosed with Type 2 diabetes in 2014, and was under the care of a community nursing team. At the time of his death, he was injecting insulin twice a day, but the dosage had been increased several times from October 2021, when his glucose levels had become a concern.

His dose was increased from 14 units per meal to 16, after a hospital admission in January 2022. This was increased again to 18 by January 24 on the advice of his specialist diabetes nurse who said he sometimes forgot to take his dosage and ‘was not the best at looking after his diet.’

There was a further hospital admission on February 2, and, on the 15^th, his wife’s personal assistant found him collapsed at home with a suspected stroke.

At the time of this admission to York Hospital, the personal assistant, Christine Sadler, said she told staff that the insulin dosage had reached 20 units twice daily.

However, once he was being treated, a junior doctor increased Simon Howard’s dosage to 24 and 30 units with a consultant’s approval. Both doctors overrode the recommendations of two pharmacists who had flagged concerns about the medication, and Mr Howard was discharged just 24 hours later without ever being seen by a specialist diabetes nursing team on the ward.

The inquest heard that he left hospital with discharge notes that contained ‘ambiguous’ information about his insulin prescription.

This time it had been found the initial diagnosis of a stroke was incorrect and Mr Howard was thought to have suffered an overnight seizure, as he made a rapid improvement and a CT scan showed no new changes.

Only three days later he collapsed again and was admitted to York Hospital unconscious. He was intubated and it was decided that, due to complications from his brain injury in 2020, his prognosis was ‘bleak’ and he was unlikely to recover. He died on February 27 after his family agreed to withdraw treatment.

A diabetes consultant told the hearing that there was ‘no clear evidence’ of a need to increase Mr Howard’s insulin dose by 10 units on his previous admission, although his diabetes was ‘unstable’, and he considered the amount prescribed by the junior doctor to be an ‘excess’ which could have caused profound hypoglycemia.

Christine Sadler, who confirmed that Mr Howard had given up alcohol after his fall in 2020, said she was unhappy with the circumstances of his discharge on the 16th and found his notes ‘unclear’.

York and Scarborough Hospitals NHS Trust has since commissioned a Serious Incident Investigation Report into the high insulin dose, which revealed that the first pharmacist recommended it be adjusted down to 20 units.

The junior doctor, who was in his foundation year, then overruled the pharmacy, saying the increase had been recommended by the specialist diabetes nursing team, but there was no record of him ever having consulted them.

The discrepancy was flagged again by another pharmacist validating Mr Howard's discharge prescription, and, after seeking clarification, the concern was over-ruled again by the same doctor. The senior locum who approved it was also not a diabetes specialist.

The ‘root causes’ identified by the investigation were that there was no evidence that dosages were checked on admission with the specialist nurses, who also did not get a chance to review Mr Howard before he left the ward.

The report recommended more crosschecks on admission and a new system, which all clinical staff can access, containing prescription information.

Changes enacted by the Trust include diabetes training being given to all new staff and new information about insulin risks.

Specialist nurses must now document all referral conversations, and they must also be the ‘first port of call’ for pharmacists seeking validation. There is now seven-day staffing by the team across both the York and Scarborough sites and discharge clinics and reviews are always conducted.

Recording a narrative conclusion, area coroner for North Yorkshire, Sarah Watson, said: “It was unclear why he was prescribed the excess dosage. There is a factual inconsistency and it is unclear what information the hospital received. Units of 24 and 30 were recorded. Christine Sadler then told staff it was 20 and 20.

"Simon Howard died due to the consequences of the recognised exacerbating effects of excess insulin administration on pre-existing natural disease and brain injury from his fall.