Diabetic Lincolnshire patient died after hospital overdose

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Northerner

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A hospital patient died after receiving 10 times the prescribed diabetes medication, a trust has revealed.

The man died on 29 July, five days after being admitted into a hospital in Lincolnshire for increased confusion and raised blood glucose levels.

In a note to staff, United Lincolnshire Hospital Trust said "a lack of clarity" in the patient's insulin dose led to the prescription error.

It said it was investigating the incident and could not comment further.

The patient had been treated at the hospital for a lower respiratory tract infection and acute kidney injury.

Five days after being discharged, he was admitted back as an emergency on 22 July.

The briefing note from Director of Nursing Dr Karen Dunderdale, seen by the Local Democracy Reporting Service (LDRS), described how the patient's prescription of Levemir 4units was changed by a clerking doctor to Detemir 44units, despite the original dosage being clearly documented in charts from a previous visit.

www.bbc.co.uk

Diabetic Lincolnshire patient died after hospital overdose

The man was given 10 times the prescribed diabetes medication, a Lincolnshire hospital trust reveals.
www.bbc.co.uk
😱 :(
 
Omg . How dreadful
 
It’s certainly always at the back of my mind, should someone else ever have to administer my insulin for me.
 
This has concerned me a bit as the last time I was at the clinic I saw a lady doctor who was new to diabetes and she asked me my Levemir doses which I said were 16 in the morning and 7 to 8 at night. When my GP practice received the report she had recorded it correctly as 16 units in the morning but 78 units at night.... that would be enough to see me off if I was admitted to hospital unconscious and administered insulin from those notes!
 
Just awful.....

The sad thing is that this isn’t the first time someone’s insulin has been messed up in hospital with extremely serious consequences - and it won’t be the last. It’s also far from the first time careless or negligence in recording or working out a dose has resulted in serious harm or death - even of children and very young babies.

The ‘Insulin Passports’ they introduced some time ago were supposed to help stop things like this happening, but still mistakes continue. Ignorance, arrogance and carelessness.
 
Others managing my insulin is something that worries me too, as I don’t need the amount of insulin they think I need.
Last time I was admitted overnight , I had a bit of a battle to keep my insulin out of the locked draw in my locker , another nurse came to my aid and explained things to the sister who was the one insisting on locking it away.
 
bring you own sandwiches as well,quite difficult to get fed outside of orderly rounds and they never have sweetners for coffee and tea
 
I'm shocked but not surprised when reading the article. About 40 years ago I was overdosed by 4 x the amount of insulin and given the wrong type as well. End result I was given a b*locking for daring to have such a bad hypo on the ward. It was obviously all my fault even though I had no access to my insulin at the time. The cover up was spectacular.
 
This is shockingly the case as I experienced this in 2017 when admitted to hospital in an emergency. All my meds, including insulin, were taken off me, put in a locked drawer in my bedside cabinet & administered by the nurses who had the keys. I was put on a sliding scale of doses & my blood sugars were very high for the 2 days I was in as the doses were so much less than what they’re supposed to be: started at 2 units & went up 2 each time; I gave them all my doses info on admittance!

But, to be fair all the other times when in hospital for various ops & things, I have been able to test & administer my own insulin etc. as the nurses don’t really know about diabetes.

I preferred that rather than being at the mercy of enforced doses I have no control over!
 
My Dad used to tell us about how the hospital almost killed his mother back in the 1950s by leaving her on a trolley in the corridor, having been given insulin, and her meal was left on the ward. It was only because my grandad forgot to give her something when he visited and sent Dad back with it that she was found to be unconscious not asleep. Dad said that he'd never seen nurses run so fast, but Grandma was never the same after that and died a few years later. I remember she used to call me 'Babs' which was her sister Barbara.
 
Always a battle but i always win the war. Everytime i'm in hospital my diabetic bag meter, strips, creon etc.. are always in my sports bag. I give them my medication apart from this bag. Always an argument but i will not let them take my insulin or creon. Eventually they give in. By the end of the day i'm telling them i,ve had x amount of units of humalog and 5 creon with my food which i also take in or get brought in at visiting times. They fill out their forms and everyone is happy. it is a pain when your not well. But i'd sooner put up a fight than risk wrong insulin doses. I've been through too much to let an overdose of insulin kill me.
 
Hepato-pancreato said:
Always a battle but i always win the war. Everytime i'm in hospital my diabetic bag meter, strips, creon etc.. are always in my sports bag. I give them my medication apart from this bag. Always an argument but i will not let them take my insulin or creon. Eventually they give in. By the end of the day i'm telling them i,ve had x amount of units of humalog and 5 creon with my food which i also take in or get brought in at visiting times. They fill out their forms and everyone is happy. it is a pain when your not well. But i'd sooner put up a fight than risk wrong insulin doses. I've been through too much to let an overdose of insulin kill me.
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I do similar. My diabetes gear including insulin stays in my handbag and I inform them of the doses I have had. I hand over my tablets.
They always want me to keep my asthma inhalers to hand.

Most of the ward staff think it strange that as, a T2 I am on MDI and work out my own insulin doses rather than on fixed doses or even worse imo that I am not on mixed insulin.
 
Robin said:
It’s certainly always at the back of my mind, should someone else ever have to administer my insulin for me.
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Robin,

Relying on someone else in "health" "care" IS the ONLY thing that regularly haunts my mind. Be it in old age in a "care" "home" or in a hospital admission. Like my grandma would say "it's not what you go in with.....it's what you come out with". Which revised for 2020 is "it's not what you go in with....it's if you come back out".

I've rarely been really impressed by any care given to myself or anyone else I've seen in a care home, hospital or by diabetes specialist nurse. I am however always willing and open to seeing a better experience. The only exception is my NHS dentist who is really interested in what he does and the high standards he strives for.

It seems to be endemic these days, people just don't care. It's like paying someone just isn't enough to motivate them to do more than just their hours.
 
Inka said:
That’s interesting @Ljc and @Hepato-pancreato No-one ever asked my insulin doses when I was in hospital.
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One doctor made a very big thing about it , I was told I had to inform the Sister each time I injected. Though she never said anything , I could tell by the sisters face what she though if it.

I am pretty sure the doc thought by saying this, I would capitulate , he didn’t know me very well lol. He probably put it in my notes somewhere that this ones trouble.
 
I highly recommend the orthopaedic ward at Geo Eliot Hospital Nuneaton. Ward sister was worried about my too high BG - as I was but not sure what to do - she said she'd come back with a ketone meter which she did (though had had to borrow it from the Children's ward) - I didn't have one as never ever been so ill before let alone breaking my patella and having to have it pinned and wired. Have had spiking BG at odd times, but on those occasions I usually find I've entirely forgotten to bolus for a meal - how the hell I can do that beats me but there it is. Expect I was far too interested in summat else at the time - of course I try not to be but sh£t happens sometimes and the immediate correction dose always works, nobody died.

If something like that happens to other T1s, and so your meter tells you to, do you bother to test for ketones when you've already got to grips with why and had a correction dose of more than you'd need for a lower high?

Anyway - she asked a clinic DSN to come and see me, which she did and brought with her an Abbott Freestyle meter with 10 strips some of which I needed to use whilst I titrated my basal up to 300% !! Good grief. Never in my wildest dreams could I have guessed that increase - took weeks and weeks recovering at home and subsequently going for more X rays and then physio, to get it back down to pre-op levels. That was a few years ago - and I haven't needed a single other ketone strip since. Dunno if the meter battery is still OK and spose I ought to check the expiry date on the strips.

Can you use em in the Libre or only BG ones?
 
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