Diabetic Lincolnshire patient died after hospital overdose

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.

The medication name was changed by a second prescriber who noticed the error the following day, but the dosage was not picked up.

Mrs Dunderdale said: "The patient was subsequently administered 44units of Levemir but the discrepancy of greater than a 10-fold increase from the previous prescription was not noted and he subsequently suffered a loss of consciousness and neurological injury some 15 hours later almost certainly secondary to profound hypoglycaemia from which he never recovered."

She said there were several missed opportunities in identifying the serious blunder.

"Prescription errors are typically events that derive from slips, lapses or mistakes," she said.

"Within this incident it would appear that there was a lack of clarity around the patient's insulin dose which led to the wrong dose being prescribed.

"This was compounded by the fact that the second prescriber transcribed the incorrect dose."

In a statement sent to the LDRS, Mrs Dunderdale added: "We would like to offer our condolences to the patient's family."

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