A Prefilled Syringe That Contained No Insulin

A British court has found a pharmaceutical firm to be at fault for a man’s death from diabetic ketoacidosis (DKA) after a prefilled insulin syringe made by the firm failed to contain any insulin.

Neil Judge, 58, died of DKA at the Northern General Hospital in Sheffield in November 22nd, 2010. According to a Mirror (UK) report, Judge required insulin while being hospitalized for an amputation; he had pancreatic disease, not Type 1. Two days after the injection, he died of multiple organ failure. It was later determined that the pre-filled syringe contained only saline, not saline and insulin, and the coroner’s report ruled lack of insulin was a “major contributing factor” in his death.

According to a recent BBC report, a British court has fined the company, Fresenius Kabi, 500,000 pounds (a little more than $750,000) for its role in Judge’s death. A Fresenius company executive admitted that some 160 pre-filled insulin syringes were found to be faulty, but only 30 were recovered for testing. That could mean that the remaining syringes were either thrown away or used. The company ceased making prefilled insulin syringes after Mr. Judge’s death.

The published report of the court’s findings fails to answer one critical question: why wasn’t it noticed by medical staff at the hospital that the insulin injection failed to bring down Judge’s blood sugar levels? According to the Mirror article, doctors only realized their error 14 hours after the injection, at which point it was too late to save his life.

This kind of tragedy reinforces the idea that it’s best for people on insulin therapy to have a support team in place that can advocate for their needs in a hospital setting. Advocates, be they friends or family, should know a patient’s normal insulin regimen, blood sugar range, and symptoms when blood sugar levels go out of bounds, and contact information for the patient’s primary care physician. Such an advocate should be brought up to speed on a patient’s* diabetes well before a hospitalization might occur.

*Insulin Nation writers normally don’t refer to people with diabetes as “patients”, but we felt it made sense when discussing hospitalization.

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Craig Idlebrook is a past editor for Insulin Nation, Type 2 Nation, and Información Sobre Diabetes. He is now the community engagement and content manager for T1D Exchange.

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