MYSTERY surrounds how a man died in hospital after a blood sample which showed to have unexplained high levels of insulin was revealed to be contaminated.

Former Ross-on-Wye swimming pool manager Leslie James died on September 30, 2013 but due to the complex investigation which followed, the inquest into his death took place this week.

Mr James, aged 85, was taken into Hereford County Hospital following an unwitnessed fall at Birchams Grange in Eastnor.

The inquest at Herefordshire's Coroners Court heard he developed hypoglycemia in the days before he died which Dr Emma Wales said was unexplained. As she had never seen readings showing such low blood sugar levels before, she ordered a blood test on the morning before he passed away.

The blood test which Dr Wales required could not be done at Hereford. The blood sample was stored in a freezer at the hospital's lab for a month, which head of blood sciences department, Julie Davies, said was an oversight and the procedures have been updated to ensure this does not happen again.

Once the blood serum sample arrived in Cardiff to be tested, it was revealed there was a very high reading of insulin, which Mr James was not prescribed and further tests revealed it was not insulin produced by the body but manufactured insulin.

This caused concern for the staff who then sent it on to forensic scientists for further testing. At this point, Mr James had already been cremated and a post mortem had not been carried out as he was thought to have died from old age and dementia.

Forensic scientist, David Mallett, said when he tested the sample there was DNA from at least three different males. He was able to compare this to the DNA of Mr James' son, Roger, and he said he was unable to exclude the James parental line from the sample.

It was unknown as to how the sample became contaminated between when it was taken by a doctor in Hereford and when it arrived in Cardiff.

Diabetes consultant, Dr Bodansky said the levels of insulin in the sample were 10 to 50 times higher than therapeutic levels and would have hastened death.

The levels of insulin could have been from one injection. But he also said hypoglycemia has other causes, although rare.

Clinical director of pharmacy at Hereford, Anthony McConkey, said on the ward where Mr James was, the door to the medicine cupboard and the door to the fridge where the insulin was stored, was meant to be locked. But that this did not always happen. There is now a digital system in place.

The inquest also heard there were no patients on the ward at the time who were self administering insulin or were prescribed insulin.

Detective Sergeant Tim Powell said that they had considered a number of different hypotheses after becoming involved on November 7, 2013.

DS Powell said the most likely hypothesis is that a nurse mistakenly gave Mr Powell the insulin. However, he said there was no evidence to prove this and that this was only the most likely explanation.

He said: "It could have been a mistake. Drug errors have occurred in hospitals before."

Roger James told the inquest he was extremely shocked when the police turned up at his door in December 2013 to tell him they were investigating his father's death. He said his dad was a boxing coach, and ran marathons up until he was in his 70s. He said when he was the manager at Ross-on-Wye Swimming Pool he would run ten miles in the afternoon.

Coroner Mark Bricknell said there had been many twists and turns during the investigation, which showed no criminal intent but shortcomings in procedures regarding medicine storage and the delay in submitting the sample for testing.

He said as a result of the delay a post mortem could not be carried out which was "disappointing."

Mr Bricknell said: "We are left with the unusual but possible readings prior to death and the tested sample definitely recording manufactured insulin."

He said the only safe conclusion was to record the cause of death as unascertained and he recorded an open conclusion.

Roger James said: "This has been a long, difficult and drawn out process and we are grateful for the findings of the coroner. We are glad that measures have been put in place by the hospital to correct shortfalls that were identified in their practices to ensure more stringent procedures are followed in the future.

"We appreciate it was a complicated case and although we will probably never truly know what happened to Dad, we acknowledge the open verdict at the inquest.

"We are grateful to all those involved in the investigation and would like to thank Hereford Hospital, particularly Dr Wales, the police led by DS Powell, Lanyon Bowdler Solicitors and also the coroner Mark Bricknell and the coroner’s officer.”