Trust gave overdose of insulin twice

What happened

Mrs J had type 2 diabetes and was cared for by her daughter. When she went into hospital with heart failure, nurses gave Mrs J was twice an overdose of insulin. They failed to notice initially that Mrs J had hypoglycaemia (very low blood sugar), which had been caused by the overdose of insulin, and they did not treat this for a period of time. Nurses did not ask doctors to review Mrs J, and the amount of insulin Mrs J was prescribed was not changed on the electronic prescription system, so she was overdosed again.

Mrs J was increasingly unwell from the heart failure and had the distressing symptoms of hypoglycaemia. Her condition deteriorated and she died a few days after she had been admitted to hospital.

Mrs J's daughter, Mrs K, complained about the care given to her mother and that the lack of management of her mother's diabetes had caused her to deteriorate further. She did not believe the Trust had done enough to address the failings identified or to report them.

What we found

We partly upheld this complaint. There were a number of missed opportunities to review Mrs J's insulin and take action, both in terms of communicating with Mrs J and her Family and also in staff reporting incidents. The Trust recognised some failings but we did not consider the action taken had gone far enough. The Trust did not recognise that there were a number of incidents that staff should have reported. There was also no action taken to address this lack of reporting.

The Trust recognised the failings in the diabetic management of Mrs J. However, we considered that the Trust needed to show how it would make sure that staff managed patients with diabetes in line with the relevant Trust policy.

Mrs J suffered unnecessarily with the symptoms of hypoglycaemia which caused her and her Family significant distress during the last few days of her life.

Putting it right

The Trust apologised to Mrs K and her Family and paid £500 in recognition of the unnecessary distress caused to them. The Trust agreed to prepare an action plan to address the issues identified in the reporting of incidents and diabetic management.