Insulin Administration Negligence Case Study: Hypoglycaemia, Falls and Post-ICU Care Failures

This case highlights a series of critical failures in insulin management, clinical handover, and inpatient safety following a patient’s step-down from intensive care. It demonstrates how lapses in basic processes, when combined, can quickly escalate into life-threatening harm.

The patient had been recovering from diabetic ketoacidosis (DKA) and was transferred out of ITU to a general ward. At the time, they remained nil by mouth (NBM) and were dependent on nasogastric (NG) feeding for nutritional support. Despite this, they experienced a severe hypoglycaemic episode and multiple inpatient falls shortly after transfer.

An Apex insulin administration negligence expert witness was instructed to assess whether the care provided met an acceptable standard. The findings pointed to a pattern of systemic failures across insulin administration, monitoring, communication, and falls prevention.

Unsafe insulin administration negligence

At the centre of the case was the administration of insulin in circumstances that were fundamentally unsafe. Within 24 hours of leaving ITU, the patient received two doses of intermediate-acting insulin (Insulatard), each 30 units, spaced just over four hours apart.

This occurred despite there being no evidence that the patient had received adequate nutrition. The patient was NBM, and there was no clear documentation confirming that NG feeding was running at the time. In fact, evidence later showed that the NG feed had not been restarted due to issues with the feeding pump.

Equally concerning was the absence of a blood glucose (BM) reading prior to one of the insulin doses. Without this, there was no clinical basis to justify administration or assess immediate risk. Documentation relating to feeding, fluid intake, and glycaemic monitoring was incomplete, leaving significant gaps in the clinical picture.

The combination of insulin administration without nutritional support and inadequate monitoring created a predictable risk of hypoglycaemia - one that ultimately materialised with serious consequences.

A breakdown in handover and clinical communication

A key contributing factor in this case was the failure of effective clinical handover. The nurse responsible for administering insulin had not received a proper handover due to an emergency situation on the ward.

While operational pressures are a reality in acute settings, this does not remove the requirement for safe processes. Administering high-risk medication such as insulin without a clear understanding of the patient’s current condition, feeding status, and care plan represents a significant patient safety breach.

There was also no evidence of escalation when it became apparent that the NG feed had not been restarted. The absence of a functioning feeding pump should have triggered immediate action, including escalation to senior nursing staff or medical teams. Instead, the situation remained unaddressed.

Further gaps were evident in documentation. The fluid chart ceased mid-afternoon, no food chart was available, and there was limited record of ongoing monitoring. These omissions compounded the communication failures, making it even more difficult for staff to make informed decisions.

Severe hypoglycaemia and emergency escalation

The consequences of these combined failures were rapid and severe. The patient’s blood glucose level dropped to 0.8 mmol/L, a critically low level associated with significant risk of neurological injury and death.

A Medical Emergency Team (MET) call was initiated, and the patient required urgent intervention. They were subsequently readmitted to ITU with severe hypoglycaemia.

This episode was not an isolated or unpredictable event. It was the direct result of unsafe insulin administration in the absence of nutritional support, compounded by inadequate monitoring and communication breakdowns.

What safe insulin management should look like

In high-risk patients, particularly those recovering from DKA and unable to take oral nutrition, insulin management requires careful coordination. Clear protocols should be in place to guide insulin administration when patients are NBM, ensuring that glucose levels are stabilised without increasing the risk of hypoglycaemia.

Effective handover is equally critical, particularly during transitions of care such as step-down from ITU. Staff must have a clear understanding of the patient’s current status, including feeding arrangements, medication plans, and monitoring requirements.

Where NG feeding is delayed or interrupted, this must be recognised as a clinical risk requiring prompt escalation. Supporting documentation, including fluid charts, food charts, and BM recordings, must be complete and up to date to inform safe decision-making.

In this case, the absence of these safeguards resulted in a cascade of preventable errors.

Falls prevention failures following deterioration

Alongside the insulin-related incident, the patient experienced two inpatient falls after returning to the ward. These events raised further concerns about the standard of care.

Falls risk assessments were either delayed or not completed at all following the patient’s deterioration. Although the care plan identified a need for high-visibility bed placement and 1:1 observation, these interventions were not implemented in a timely manner.

The first fall was not supported by a clear care plan or investigation record, limiting understanding of the circumstances and any learning points. The second fall occurred despite the known risks, and at a time when the patient was not receiving the level of supervision outlined in their care plan.

This suggests a failure not only to identify risk, but to act on it consistently.

A pattern of systemic failures

When viewed in isolation, each of these issues - insulin timing, missed observations, incomplete documentation, or delayed falls assessments - might be seen as individual lapses. However, in this case, they formed part of a broader pattern.

The expert identified a systemic breakdown in clinical safety processes, where multiple layers of protection failed simultaneously. There was inadequate handover, unsafe medication practice, poor documentation, lack of escalation, and ineffective implementation of care plans.

Importantly, the risks in this case were foreseeable. A patient recovering from DKA, who was NBM and dependent on NG feeding, required careful monitoring and coordinated care. The failure to provide this fell below the expected standard of both nursing and medical practice.

Conclusion: foreseeable harm and avoidable outcomes

The expert concluded that the patient was exposed to avoidable harm as a result of these failures. The severe hypoglycaemic episode and subsequent falls were not random events, but the outcome of unsafe systems and missed opportunities to intervene.

This case reinforces the importance of basic clinical processes. Safe insulin administration, effective handover, accurate documentation, and proactive falls prevention are not optional elements of care - they are fundamental requirements.

Where these processes break down, particularly in high-risk patients, the consequences can be immediate and severe. For both clinicians and legal teams, this case serves as a clear reminder that patient safety depends not only on individual decisions, but on the reliability of the systems that support them.