Medische en administratieve veronachtzaming van een hoge bloedglucosewaarde; aantekeningen bij een beslissing van een medisch tuchtcollege

– A 41-year-old man died in 1995 during ketoacidotic coma. He suffered from chronic manic depression, used lithium carbonate, and consulted the psychiatrist and the general practitioner (GP) frequently. Diabetes had not been diagnosed. Late in 1994 the situation worsened, the patient complaining of general illness, fatigue, nausea, vomiting, diarrhoea, thirst and excessive drinking of soft drinks. The GP referred the patient to a neurologist who found no neurological disorder but who asked for determination of blood glucose and lithium levels, and of thyroid function. The day afterwards the neurologist went on holiday. The blood glucose level proved to be elevated (16.9 mmoll) but nobody took any action and the GP was not informed. Six days after returning from his holiday, the neurologist who had an administration backlog, found the laboratory findings only after he had been informed that the patient had just died. The court gave the neurologist a warning. Lessons are that somatic problems should be treated as such, even in a psychiatric patient, and that a good administrative signalling system is a prerequisite for quality in medical practice.