A newly-qualified nurse was responsible for the unlawful killing of a diabetic pensioner who died after being injected with 10 times too much insulin, a coroner has ruled.
The actions of community nurse Joanne Evans, who was not present at Cardiff Coroners' Court to hear the verdict, were described as "more than cavalier" by coroner Mary Hassell.
The inquest heard that 85-year-old Margaret Thomas from Pontypool, South Wales, died after Ms Evans had miscalculated in her head the amount of insulin to administer. She had been using a regular syringe instead of a specific insulin syringe.
Following the incident, senior trust management decided that community nurses should be given a list of equipment to carry in their car, Ms Hassell said.
Recording her verdict, the coroner said that Ms Evans had breached her duty of care to Mrs Thomas by not taking all reasonable precautions to prevent risk of her dying.
Nurses in basic training are told that because insulin is measured in units, not millilitres, they should always use a specific insulin syringe when injecting the substance.
Ms Hassell said that despite this, Ms Evans did not seek to get the correct syringe from a colleague or the local hospital.
The Crown Prosecution Service had previously decided against bringing criminal charges, but said it would be reviewing the case in light of the verdict, meaning that Ms Evans could now face prosecution.