Coroner blames ‘cumbersome’ software for doctor’s insulin prescribing error before patient death
Audrey Jamieson said a medicine policy explained how doctors should manage new orders, yet mistakes remained frequent.
A coroner has avoided criticising a doctor over a patient’s accidental extra insulin dose, saying “cumbersome” hospital software shouldered more of the blame.
Veronica Roberts, 75, died in 2020 after receiving a 20-unit dose of insulin glargine six hours after her usual daily dose of 15 units.
She was in rehabilitation at the Mornington Centre in Victoria following a two-month admission at Frankston Hospital related to hyperglycaemia and non-ST-elevation MI.
Her BSLs were labile during her hospitalisation, between 6 and 27nmol/L, and she sometimes refused medication, Coroner Audrey Jamieson heard.
