1. Case History: Mrs JP A multi-disciplinary approach

2. Background Aged 75 years Lives alone, widowed, in a bungalow. Supportive daughter lives nearby Insulin requiring diabetes, secondary to Whipple’s for benign head of pancreas lesion Has capacity, unable to self-administer insulin - QDS regime, refuses supported care e.g. residential or nursing home

3. Admissions to Acute Trust Multiple admissions (28) in past 24 months. Usually DKA or hyperglycaemia. Increasing length of stay with each admission and quick re- admission time Reviewed for education on SDR, ketones, CHO awareness, correction dosing, injection technique Novorapid and Levemir regime, alternative options explored, including district nurse support as compliance issues being considered

4. Concerns DNs suspected water was presented for ketone testing instead of urine ? “pretending” to dial-up and inject insulin when supervised Did not always answer door to DN visits DNs could not provide support required Happy in hospital, especially weekends Manipulating insulin regime and diet intake to induce hyper or hypo glycaemia when discharge planned Psychological and behavioural issues were leading to non-compliance and life-threatening illness/admission

5. Actions Swapped from Levemir to Degludec – last resort! DNs visit morning and lunch to administer Novorapid, using s/c sliding scale with BGL Daughter to administer evening Novorapid and Degludec – since changed to mornings Algorithm developed for ketone management at home, if no vomiting Psychiatrists/psychologists and RAID team helped develop detailed care plan and community options to manage and/or prevent admission

6. Update…. Since implementation of the careplan and degludec, there have only been 5 short admissions, 3 of which could have been prevented