AUGUST, 2015

An unaccountable environment
Bureaucratic indifference
Avoidable errors

A man ended up dead from an insulin overdose only a month after being admitted to a nursing home.

The media continues to publish stories of poor quality care in nursing homes. However relatives are unable to find out which nursing homes have been subject to numerous complaints. As with hospitals, the public goes in blind to cost and quality. One of the problems is that bad staff and bad facilities are virtually never deregistered.

This leaves the general public at risk unnecessary danger from repeat offenders. It also drags down the reputation of good doctors and good nurses.

‘There is very little accountability in healthcare’ said Marty Makary.

An 70-year-old man called Carl was living alone and was recovering from a slow healing leg ulcer. Apart from having insulin-dependent diabetes, Carl was medically stable. He was independent and looked after himself well. However, Carl was lonely. After a discussion with his family, he agreed to move into a low-level nursing home, called a Hostel. The hostel looked glamorous. It was like a hotel, with large, elegant rooms and plush fittings.

As soon as he was admitted to the nursing home, Carl’s normal long-acting insulin was changed to a different, short-acting insulin. His GP was not advised of this change. Neither was Carl’s family. Carl’s blood sugars quickly became unstable. However, his new insulin regime was not reviewed by the nursing home doctor.

The nursing home staff did not take Carl’s blood sugars on a more regular basis. When Carl’s daughter came to see him, she was concerned to hear that his medications had been changed. When she discovered that Carl’s blood sugars were now unstable, she started complained to nursing staff. No clear explanation was given.

A month after he had admitted to the hostel, Carl’s daughter happened to come and visit when he nurse was changing his leg dressing. She was shocked to see how badly her father’s wound had deteriorated. The wound had been stable for months. Now it was infected and deteriorating substantially. She was extremely upset. She announced that she would be taking her father into the hospital emergency department the next day for a formal review.

“You could be in a lot of trouble” she told the nurse. “I’m going to write a formal complaint about this”.

The next time the daughter had contact with the nursing home was early the next morning. Staff rang her to say Carl was “unwell”. “What’s wrong” she asked, shocked. “His blood sugar is low, 1.5. We have rung the doctor.”

It turned out that Carl had been taken ill that evening and been put to bed. Evening staff had given him Panadol. Night staff checked his blood sugar when they came on shift and found that it was very low. He also felt sweaty. Staff discovered that Carl had lost control of his bladder. Staff changed his pyjamas and his sheets. The nursing home doctor was rung.

The nursing home doctor told the nurse to give Carl a sandwich to eat and some juice to drink. When the nurse was free, she took a sandwich down to Carl’s room. By now Carl was confused and calling out. The nurse told a care attendant to make sure Carl got the sandwich when he woke up. Early in the morning the nurse rechecked Carl’s blood sugar and found it was 1.5.

Despite the fact that Carl had an oral sugar paste called glycogen on his drug chart for emergencies it was not given to him. Despite the fact that the normal nursing home protocol was to call an ambulance if a resident’s blood sugar was below 2, the nurse did not do this. She rang the doctor instead. The nursing home doctor suggested giving Carl some jelly beans. The doctor did not call back to check on Carl’s progress.

The night nurses went in to give Carl a handful of jelly beans. By this time Carl was quiet. The jelly beans were not given. His daughter was rung.

After nursing handover at 7am the night nurse went home. The morning staff went to check the patients. They found Carl dead. It was six hours after the doctor had been rung. His blood sugar had not been checked for four hours.