Finding into death of John Charles Prohasky

66y · Male·unascertained

A 66-year-old man with insulin-dependent diabetes mellitus and severe hypoglycaemia unawareness died on 20 June 2013, the day after commencing a Medtronic Paradigm insulin pump. He was found collapsed at home after planning to change his insulin pump vial. Cause of death was unascertained. Clinical lessons include: a dietician formal assessment should have been undertaken during pump initiation, not deferred to family members, given his inaccurate carbohydrate counting; pump data from 17-20 June 2013 was corrupted preventing analysis of potential overdose; his history of severe hypoglycaemia with poor symptom recognition may have contributed; multiple Medtronic safety advisories before his death included risks of unintended insulin bolus delivery. The commencement of quick-acting insulin infusion via pump was a significant change from his prior slow-acting regimen.