Hospital nurses’ incorrect administration of insulin to an inpatient with type 1 diabetes was highlighted in an assistant coroner’s prevention of future deaths report. Northampton General Hospital ward staff had been giving Leslie Hurwood his insulin doses after meals, and not before, compromising the efficacy of the therapy. A diabetes specialist nurse at the same trust said she has continued to observe the incorrect practice and the message from insulin training only ‘got through’ to some staff. A former ward sister accepted there was no excuse for giving insulin after food, but said poor staffing was probably a factor.