Archived Princess of Wales glucometer documents and notes

(Maintained by Harold Thimbleby (email; last checked 2024.)

A very good summary of the Princess of Wales glucometer case is in this short booklet, pages 8 & 9. The booklet makes the comparison with the Post Office Horizon Scandal, which is on the following pages 10 & 11.

Table of contents

  1. Judge’s ruling
  2. Abbott Diabetes Care, Precision Web, User’s Manual QC Manager 3.0
  3. Angela Hopkins, Review of the Blood Glucometry Investigations
  4. Andar Gunneberg, Personal reflections
  5. Andar Gunneberg, Personal reflections, annotated by Harold Thimbleby
  6. Health and Safety Committee minutes and comments
  7. Experts’ Joint Statement on Matters Agreed and/or Disagreed

1. Judge’s ruling

Ruling in R v Cahill; R v Pugh 14 October 2014, Crown Court at Cardiff, T20141094 and T20141061 before HHJ Crowther QC, Digital Evidence and Electronic Signature Law Review, 14 pp67-71, 2017.

DOI 10.14296/deeslr.v14i0.2541

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2. Precision Web manual

Note that the Precision Web manual says
This product is not for diagnostic use; all patient diagnostics should be based on results reported by the point of care instrument.
See page 1-2 of the manual.

The Precision Web database provided all computer evidence (the only evidence) against the nurses.

Full manual archived here.

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3. Angela Hopkins, Review of the Blood Glucometry Investigations

Link to Commissioned Review, June to September 2016. Review of the Blood Glucometry Investigations in Abertawe Bro Morgannwg University Health Board. Establishing lessons learned here.

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4. Andar Gunneberg, Personal reflections

Dr Andar Gunneberg, Clinical Lead for Laboratory Medicine, PERSONAL REFLECTIONS ON PROFESSOR HAROLD THIMBLEBY’S REPORTS ON BLOOD GLUCOMETRY AT THE PRINCESS OF WALES HOSPITAL, BRIDGEND, dated 5 May 2017.

The original of this seems to be no longer available on the NHS web site but an archived local copy is here.

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5. Andar Gunneberg, Personal reflections, annotated by Harold Thimbleby

I have annotated a version here, noting problems with Gunneberg’s reflections.

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6. Some Quality and Safety Committee minutes and comments

If the following NHS link does not work then is a local archive held here.

It contains the following minutes, with my brief comments shown like this:

6.6.9 In support of greater understanding of issues associated with the blood glucometry system it is recommended that all staff investigated, together with those staff involved in the investigations, the case note reviews, internal assurance review process and in the management of the Precision Web system, should be required to read the report prepared by Professor Thimbleby for the court, together with the Judge’s ruling, and complete a written reflection on the contents. — This didn’t happen, with the exception of Gunneberg's notes which are available archived on this page above.

It is also recommended that Professor Thimbleby is invited to engage in a filmed recording for educational purposes and to inform the Board on the findings which were presented to the courts. Action within 3 months from approval of the report. Christine Morrell, Director of Therapies and Health Science Exec Lead June 2017. — This didn't happen at all.

POCT advise that Professor Thimbleby was asked to review the Abbott meters and Precision Web by ABMU HB in 2013 by Steve Coombe, POCT manager was asked to meet with him and Steve Coombe to explain the operation of the meter. There was also a visit arranged to Singleton Hospital where POCT coordinator (LP) showed him the system in working practice on a ward. Professor Thimbleby did not report any concerns in 2013. — I wrote this review of the Abbott glucometers prior to the court case. I did not have access to the Abbott Precision Web system (or refer to it in my report), which is where all the faults lay — so, unsurprisingly, the review makes no mention of any concerns relevant to the case as it hadn’t yet happened.

Subsequently Professor Thimbleby became an expert witness for the defence. June 2017 .' Angela Hopkins presented a lessons learned talk which was attended by Clinical Director of Laboratory Medicine who produced feedback and a reflective report in regard to Professor Thimblebys report — I attended this meeting. The Clinical Director’s talk to the full lecture theatre at the Princess of Wales hospital completely ignored every finding of the court case — in particular they had clearly not read (or chose to deny) the Judge’s ruling that the Hopkins report had asked them to reflect on. I started to stand up and was physically not allowed to speak (I would have contradicted the Clinical Director who had claimed there was nothing for the hospital to worry about because three nurses had been convicted — so the problem was solved and the hospital remained blameless).

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7. Experts’ Joint Statement on Matters Agreed and/or Disagreed

See Experts’ joint statement

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