Overview
- The coroner ruled that 77-year-old Donald Gough died from brain damage caused by severe hypoglycaemia after an insulin dose was apparently injected under the skin during surgery on October 6, 2022.
- The inquest found clinicians treated his prolonged drowsiness as an opioid effect and several doctors failed to act on blood gas results, leaving low blood sugar untreated for hours and contributing to his collapse and later death on November 5, 2022.
- Insulin was likely given during skin closure by junior staff but the coroner could not identify who administered it and found no evidence of malicious intent.
- Cardiff and Vale University Health Board told the court it accepts civil liability and said it has made changes, and South Wales Police interviewed staff after the death but brought no criminal charges.
- The case highlights system weaknesses such as reliance on human triple checks, inadequate handover and staffing gaps including absent assistant anaesthetists, and it pressures hospitals to strengthen protocols for drug management and post-operative monitoring.