This case involves a seventy-nine-year-old male patient with a past medical history of very poorly controlled diabetes and resultant diabetic foot disease. The patient required daily supervision and was living with his daughter, who was his main carer at the time. The patient was receiving medical treatment a local hospital for gangrenous changes of the right foot. Conservative management was not successful and surgery was required to prevent further spread of the gangrene. The patient underwent a trans metatarsal amputation procedure and was transferred to an inpatient rehabilitation unit for further care. The procedure was deemed to be successful and the patient made a good recovery post-operatively. Shortly before being discharged, the patient was given a bolus of 15 unit of insulin by a nurse in the rehabilitation unit. The patient was transported home by his daughter. Shortly after arriving home, the patient complained of feeling unwell and went to bed. The daughter found the patient unresponsive in bed. He had no pulse and was not breathing. She initiated CPR and called for an ambulance. The patient was immediately transferred back to the hospital but remained in a critical condition after sustaining cardiopulmonary arrest. The patient never recovered and died following a long hospital stay.
Question(s) For Expert Witness
1. Should this patient have been given the insulin so soon before discharge without close monitoring by nursing staff?
2. Should any tests have been ordered before administering the insulin dose to ensure that the patient wasn't already hypoglycemic?
Expert Witness Response
The dosage of insulin administered to this patient seems quite large. There are many different formulations of insulin, with variations in the onset, duration, and length of action, and even greater variability according to the patient's renal function, so the specific details of the type of insulin that was given and the time lapsed is a key point. In addition, health care facilities have policies governing the administration of insulin and monitoring of blood glucose levels, begging the question as to whether this is an issue of failure to follow policies in the transferring and transporting health care organizations. On the surface, it would seem that reasonable nursing judgment was not used in this case. The nursing staff should have hesitated in giving that much insulin immediately prior to discharge and they should have taken a finger-prick blood glucose reading before administering the insulin to measure the patient’s blood glucose levels. A thorough review of the patient's complete laboratory panels prior to discharge from the original facility is warranted in this case. Other electrolyte abnormalities may predispose the patient to developing cardiac arrhythmias and the subsequent need for CPR. However, on the face of things, the large dose of insulin without monitoring seems very problematic.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
