Finding into death of Marie Goder

84y · Female·Major cerebral infarct due to hypoglycaemia

Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. After 8 units of Actrapid insulin at 21:15, no blood glucose level (BGL) monitoring was documented until 5:05 am the next morning when she was found unresponsive with a BGL of 0.8 mmol/L. The coroner identified multiple deficiencies: inadequate BGL monitoring despite sliding-scale insulin requiring close supervision; poor documentation of medication administration and BGLs; use of short-acting insulin in a nursing home setting without adequate staffing or protocols; lack of clear therapeutic goals; and failure to appreciate the significant risk of hypoglycaemia in elderly diabetics. Key lessons include the need for clear diabetes management protocols, frequent BGL monitoring when using sliding-scale insulin, adequate nursing staff, proper documentation, and consideration of hospital admission when nursing home resources are insufficient.