Hypoglycaemia can be associated with critically ill patients and is often indicate a preterminal event due to multi organ failure. Frail elderly patient from nursing home with multiple medical problems with an acute catastrophic illness often get transferred to hospital for end of life care at the request of the family or the GP. Minimal investigations and enquires once the decision to palliate the patient are all agreed by the family, GP and the nursing home staff.
We report a case series of three elderly frail patients from a high care nursing home presented with profound hypoglycaemia, which were initially, diagnosed as part of severe sepsis by emergency department. They were managed palliatively and one has already died. The missed diagnoses were discovered and were subsequently confirmed due to exogenous large dose insulin administration. The offending carer was eventually identified and was successfully prosecuted. One patient died in subsequent days due to complications of hypoglycaemia. The remaining patient survived the event and moved to a different nursing home.
We will present the sequence of events that lead to the diagnosis of the insulin over dose. We will review the literature on large dose insulin pharmacokinetic and the phenomenon of health care serial killers (HSK).
Physician need to be vigilant with these cases of health care serial killers (HSK), which have intermittently occurred. Insulin is one of the commonest methods