Hospital errors contributed to the death of a woman five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertain severity”, recorded Suffolk’s senior coroner, Nigel Parsley. “Sue never fully regained consciousness, so the extent of that brain injury could not be meaningfully assessed,” he said. Following the inquest, Susan’s husband, Jon Warby, said: “While nothing will ever bring Sue back, the one positive to come out of all this is the action being taken to protect future patients. “I hope no other family has to go through what we have.” Warby was admitted to West Suffolk, the local hospital of the health secretary, Matt Hancock, after complaining of abdominal pain, vomiting and diarrhoea for about a fortnight and collapsing at home on 26 July 2018. She died on 30 August that year after a series of complications in her treatment. Speaking after the inquest was adjourned in January, Jon Warby said he was “knocked sideways completely” when he received an anonymous letter two months after her death highlighting blunders in her treatment. Doctors at the hospital were reportedly asked for fingerprints as part of the hospital’s investigation into the letter, a move described by a Unison trade union official as a “witch-hunt” designed to identify the whistleblower. Following January’s adjournment, Parsley instructed an independent expert to review the care that Warby, a mother of two, received, with Dr Ken Power, a consultant in anaesthesia and critical care medicine, presenting his findings during the hearing on Monday. Warby’s medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia, pneumonia and perforated diverticular disease, affecting the bowel. Recording a narrative conclusion, Parsley wrote: “Susan Warby died as the result of the progression of a naturally occurring illness, contributed to by unnecessary insulin treatment caused by erroneous blood test results. “This, in combination with her other comorbidities, reduced her physiological reserves to fight her naturally occurring illness.” Jon Warby, a former police officer, said in a statement: “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here. “The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened. “After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. “The trust has now made a number of changes which I am pleased about.” Amie Minns, a lawyer at Irwin Mitchell representing Warby’s family, said: “The inquest identified worrying issues in the care Susan received prior to her death, and it is clear that the trust has made a number of significant changes to improve patient safety, which we welcome. “We wouldn’t want any other family to endure the heartbreak and pain that Jon and his family have.” A spokesperson for the West Suffolk NHS Foundation Trust said: “We offer Mrs Warby’s family our deepest sympathies. Aspects of her care could and should have been better and for this we apologise. “Since this case we have introduced a series of additional procedures and safeguards, but we will review the coroner’s findings in detail and continue to strive to improve the quality of the care we provide to our patients and their families.”