A woman died after poor handwriting on her hospital records led to her being given 10 times too much insulin, a fatal accident inquiry has found.
The drug records for Mrs Pullar had been misread
Moira Pullar, 62, died at Monklands General Hospital on 17 January, 2004.
Airdrie Sheriff Court heard the nurse who gave the wrong dose failed to have it checked or consult a doctor.
Sheriff Robert Dickson commended Mrs Pullar's family for preparing their case themselves because legal aid was unavailable.
The cause of Mrs Pullar's death was given as bronchial pneumonia following brain damage and cardiac arrest due to an insulin overdose.
The sheriff found that poor handwriting of earlier entries in the diabetic records by one nurse, Fiona Thomson, was misread by another nurse, Kathleen Walker.
Confusion over new nursing practices on 11 January also meant that the warning signs of the overdose were overlooked and the opportunity to reverse the effect was lost.
Mrs Pullar died six days later.
The nurse responsible for Mrs Pullar, Nurse Walker, misread the handwriting on one of the patient's charts on the morning of Saturday, 10 January, and instead of giving four units, she gave a dose of 40 units of insulin.
In his ruling, Sheriff Dickson said: "She did not have this dosage checked by another nurse as would have been proper and appropriate practice."
He said the cause of Nurse Walker's mistake was the handwriting of Nurse Thomson.
Sheriff Dickson said: "It is therefore appropriate that Nurse Thomson's involvement is recorded as a factor in Mrs Pullar's death.
"Had she written the figures clearly for Saturday morning (and her entries for other times are little better) then this tragedy would not have happened."
The inquiry also found that that the nurse responsible for Mrs Pullar's care on 11 January, Lindsay Walker, failed to monitor her adequately and a deterioration in the patient's condition was not properly noted.
While the nurse did raise the alarm with other staff, she did not return to Mrs Pullar to see if her condition had altered.
Nursing staff on that day were confused by the trial of a new system of working, which certain nurses had no experience of.
Sheriff Dickson said: "I have therefore concluded that there was a failure in the system for recording and prescribing insulin within ward 14 and that this must be recorded as a defect in a system of working which contributed to Mrs Pullar's death.
"There was a defect in the system of nursing whereby insulin doses were given without a doctor's prescription or supervision.
"There was also a defect in the system of nursing on 11 January whereby there was a lack of clarity as to who was to be responsible for the taking of blood sugar levels for patients requiring these readings whereby no reading was taken for Mrs Pullar pre-lunch.
"These two defects in the system of working contributed to the factors which led to her death."
The court heard that Mrs Pullar's prescription chart had been deliberately altered after the overdose was given, but that it was impossible to tell who had altered it.
A spokesman for NHS Lanarkshire apologised to the family.
He said: "Action has already been taken to address many of the issues raised in the sheriff's determination and we will study the report in detail to establish if any additional action can be taken."
A spokesman for the Scottish Legal Aid Board said the initial application for aid failed because it did not show how the family's line of questioning would be different from the procurator fiscal's.
He said an urgent appeal for aid, under a different process, would have been highly likely to have been granted.