Decision Report 201901956

  • Case ref:
    201901956
  • Date:
    August 2020
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C was diagnosed with diabetes (a condition that causes a person's blood sugar level to become too high) and they were given treatment with insulin (a hormone made in your pancreas. It helps your body use glucose (sugar) for energy. In type 1 diabetes your pancreas no longer makes insulin, so you have to inject it to control your blood glucose levels) and had follow-up care with the diabetes clinic. After several months, C decided to stop injecting insulin as they felt that this caused pain in their legs. C complained that the board had misdiagnosed them, that insulin had caused pain in their legs, and that their concerns were not taken seriously by staff at the diabetes clinic.

We took independent advice from a consultant diabetologist (doctor specialising in the diagnosis and treatment of diabetes). We found that once the diagnosis of diabetes had been made, insulin was the correct treatment and was reasonable. However, we found that it appeared that there had been a missed opportunity to diagnose the diabetes several months earlier and this was unreasonable. On this basis, we upheld C’s complaint. We also found that the pain C had experienced could have been caused by the administration of insulin. Whilst we were clear that insulin was the correct treatment for C, we suggested that the board could have acknowledged the possibility of the insulin contributing to C’s pain.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for failing to diagnose them with diabetes at an earlier point. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets .

What we said should change to put things right in future:

  • Where low blood sugars indicate a diagnosis of diabetes, this should be followed up.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: August 19, 2020