Tragic mix-up at University Hospital of Wales: In a heart-wrenching incident, mistakes and system failures led to the untimely death of 77-year-old Don Gough after he was mistakenly injected with insulin instead of anaesthetic post-surgery. An inquest revealed that no one intended harm, but breakdowns in human checks contributed to this tragic event.
Great-grandfather and former NHS worker, Don’s unexpected passing shook his family and community. He was known for his dedication, humour, and passion for golf and football. An X-Ray suite now bears his name in honour of his legacy.
Coroner David Regan highlighted significant lapses: junior surgeons stitched up Don without realising insulin had been injected instead of the intended pain relief. Multiple doctors missed crucial signs of low blood sugar, treating him instead for effects of opioids, even though tests pointed to the real issue. This oversight was further compounded by a lack of proper communication during handover between surgical and recovery teams.
Despite extensive investigations and no malicious intent found, these errors proved fatal. After slipping into a coma in the recovery room, Don sadly passed away a month later. The case has prompted Cardiff and Vale Health Board to review and improve their procedures, though no legal action or criminal charges have been pursued.
Our thoughts remain with Don’s family during this difficult time, hoping they find some solace in knowing his life and contributions are remembered and valued.