A CORONER has raised the alarm after a Bolton dementia patient with a low blood sugar level was given insulin by an agency nurse.

Rachel Galloway, a Manchester West assistant coroner, at a Bolton inquest in July, ruled that diabetes and Alzheimer's sufferer Robert Rostron's death 13 months later would not have occurred without the dose.

Her prevention of death report has now been published by the Chief Coroner, seeking answers from HC-One, the owners of Four Seasons Nursing Home, in Breightmet, where Mr Rostron was cared for.

An agency nurse, who had only been shown around for the first time that day by a healthcare assistant, was in charge of his unit, back in September 2017.

He noticed, on a medication round, the coroner's court heard, that Mr Rostron had a blood sugar reading of 2.2. This would usually have required the administration of a sugary drink. But the nurse gave the patient his usual insulin dose instead.

The inquest heard the nurse did not check on Mr Rostron again until a few hours later, when he was 'unconscious and unresponsive'.

He was taken to the Royal Bolton Hospital and revived, though the court heard he never recovered to his previous levels and died on June 25 last year. An investigation later established that the nurse did not have access to Mr Rostron's medical records or care plan.

Mrs Galloway said: "I am concerned that agency nurse was used as the senior member of staff in charge of the shift."

A HC-One spokesman said: "Our thoughts and sympathies are with Mr Rostron’s family, and we apologise sincerely for what happened in 2017.

"Since the incident, we have worked hard to learn from what happened and to share these learnings across our organisation

"For example, we have revised and updated the resources agency staff need in order to ensure kind, high quality care is delivered to all residents, safely and accurately.

"Additionally, following discussions with agency suppliers, all agency nurses who work in our homes are now required to provide proof of their skills, knowledge and up-to-date training in administering insulin safely."

The firm said while agency usage was being cut, nursing recruitment remained 'immensely challenging'.