“What happened to me in the night?” — telling a patient about your own prescribing error

Candidates: do not open until you have consulted.

Persona and manner

• Joan Tomlinson, 74, widowed, a retired school cook — practical, direct, proud of managing her diabetes well for years (“I’ve never had a hypo in my life”). Your daughter Debbie, 48, visits every afternoon.
• You are frightened by what happened and want a straight answer. You are not angry to begin with; you become angry only if you feel fobbed off, if the explanation is vague, or if you are made to feel it was your fault. You are capable of generosity if treated honestly.

Opening line — say this verbatim

• “The consultant said something went wrong with my insulin. What happened to me in the night, doctor? I felt dreadful — I didn’t know where I was.”

Volunteer freely if given the space

• You woke drenched in sweat, your heart pounding, and thought you were at home; the nurse was “shouting my name”. You remember a needle and a drip, then feeling yourself again.
• You had a second funny turn about six — “they gave me some sugar”.
• You have a drip in your arm now and the nurses are pricking your finger every hour; nobody has told you why.

Only if asked

• Your usual insulin: 8 units of the long-acting one every night at ten, for six years; you told the admitting doctor and the nurses “eight”. If asked what happened when the nurse gave last night’s injection: “She said the chart said eighty. I said ‘that’s a lot’. She said it’s what the doctor had written. I thought the hospital must know what it was doing.”
• You feel “washed out”, a bit of a headache, otherwise well. No chest pain, no weakness, no trouble speaking. You can remember this morning clearly.
• You do not drive — you gave up two years ago. You live alone in a bungalow; Debbie does the shopping.
• You have never had a hypo at home. You know the symptoms from the diabetes nurse years ago.
• If asked about Debbie: she is coming at eleven. “She’ll want to know everything. She was already cross that my tablets were late yesterday.”

Impact on daily life — home and work (only if asked)

• You are frightened to go to sleep tonight in case it happens again.
• You are worried about going home alone if your sugars are “all over the place” — you have always managed on your own and do not want Debbie fussing.
• You are a little ashamed that you did not insist when the nurse said eighty.

Ideas, concerns and expectations

• Idea: that somebody mixed up the dose — or that it was your fault for not arguing with the nurse.
• Concerns: will it happen again tonight? Has it done any damage — “my brain, my heart”? Who gave me ten times the dose, and why did nobody check? And — once the doctor has been honest — “will you get into trouble for this?”
• Expectation: a straight account of what happened, an apology, to be told what is being done so it cannot happen again, and for Debbie to be told too.

Cues to deliver, timed

• Minute 2, if the doctor has not yet said what went wrong: “Just tell me straight, doctor. Was it the dose?”
• Minute 4, if the doctor has not asked how you are feeling now, or whether you have questions: “Is it going to happen again tonight?”
• Minute 6, if the doctor has not mentioned what is being done to prevent it: “And what’s to stop it happening to the next person?”

If the doctor summarises and asks whether you want to add anything

• If the doctor has been honest and apologised: “There is something. Debbie took a photo of the chart this morning. She says she’s going to make a complaint. I don’t know whether to let her.”
• If the doctor has been vague or has not apologised: “You haven’t actually said sorry.”

How to respond to the doctor

• If the doctor says plainly that they wrote the wrong dose — 80 instead of 8 — that it was their mistake, and says sorry: you are quiet for a moment, then: “Well. At least you’ve told me. Thank you for that.” You soften, and you ask what happens now.
• If the doctor explains the hypo in plain words, what was done in the night, why the drip and the finger-pricks are there, and that the long-acting insulin can keep working for a day or more so the checks continue tonight: reassured — “So that’s why they keep pricking me.”
• If the doctor is vague (“there was a bit of a mix-up with your sugars”), blames the nurse (“she should have checked”), or says it was a “system error”: angry — “Don’t give me that. Who wrote eighty?”
• If the doctor says or implies it was partly your fault for not insisting: angry and hurt — “I told them eight. I’m the patient.”
• If the doctor tells you the incident has been reported, that it will be looked at so it does not happen to someone else, that the consultant and the diabetes nurse will see you today, and that you can have it in writing: satisfied — “That’s all I wanted.”
• If the doctor asks whether you would like Debbie told, and offers to speak to her with you: relieved.
• If the doctor tries to talk you or Debbie out of complaining: cold — “It’s her right, isn’t it?” If the doctor says it is her right, explains how (the ward sister, the patient advice and liaison service, a formal complaint) and that it will not affect your care: “Fair enough.”
• If the doctor promises “it will never happen again” or “there’s no damage, I guarantee it”: “You can’t promise that, can you?”
• If the doctor says “I feel terrible” or “I’m so upset”, or says sorry three times running: you notice, and you are kind — “You’re only young. Did you get any sleep?” — but you still want the answers.
• If the doctor asks whether you want the ward sister with you: “No — just you. Debbie later.” If the doctor asks whether you want every detail now or later: “All of it. Now.”

Do not

• Volunteer the nurse’s “that’s a lot” exchange or Debbie’s photograph unless asked — or invited to add anything (apart from the timed cues).
• Become abusive. Your anger is about honesty, not volume.
• Let the doctor off without an apology in words.

Domain marks — with the key facts that earn a 4 at this station

Domain score (educational construct):

This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4.

The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. The professional duty of candour (GMC and NMC joint guidance, ‘Openness and honesty when things go wrong’, 29 June 2015, since updated; check the GMC page for the current version date): every health and care professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress — tell the patient (or, where appropriate, their advocate, carer or family) when something has gone wrong; apologise; offer an appropriate remedy or support to put matters right if possible; and explain fully the short- and long-term effects of what has happened. Paragraph 10: the most appropriate team member to speak to the patient will usually be the lead or accountable clinician — here the consultant has already opened the conversation and asked the prescriber to explain. Paragraph 11: speak to the patient as soon as possible, with someone available to support them; you need not wait for an investigation, but be clear about what has and has not yet been established. Paragraph 12: share all you know and believe to be true about what went wrong, why, and the likely consequences; say what is uncertain; answer questions honestly.
2. Saying sorry (same guidance, paragraphs 14–17): patients expect to be told three things — what happened, what can be done to deal with any harm, and what will be done to prevent someone else being harmed. Apologising does not mean admitting legal liability (Compensation Act 2006, section 2: an apology, an offer of treatment or other redress does not of itself amount to an admission of negligence or breach of statutory duty); NHS Resolution advises that saying sorry is the right thing to do; a fitness-to-practise panel may view an apology as evidence of insight. A personalised apology — “I am sorry” — is more meaningful than a general expression of regret on the organisation’s behalf; the patient should know who to contact with further questions, be told about independent advocacy and support services, and the apology should be recorded in the clinical record; a verbal apology may need to be followed by a written one. You are not expected to take personal responsibility for a colleague’s mistake or a system failure — but here the error was the FY2’s own.
3. Good medical practice (GMC, 2024), paragraph 45: you must be open and honest with patients if things go wrong; if a patient under your care has suffered harm or distress you should put matters right if possible, apologise (apologising does not of itself mean admitting legal liability), explain fully and promptly what has happened and the likely short- and long-term effects, and report the incident in line with your organisation’s policy. Paragraph 46: respond promptly, fully and honestly to complaints, and do not let a complaint affect the care you provide. Paragraph 73: contribute to incident reviews and investigations.
4. The statutory (organisational) duty of candour — regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (in force for NHS bodies from November 2014 and for all other CQC-registered providers from 1 April 2015): applies to the registered provider (the trust), not to individual clinicians. For a health service body a ‘notifiable safety incident’ is an unintended or unexpected incident that, in the reasonable opinion of a health care professional, could result in or appears to have resulted in death, severe harm, moderate harm or prolonged psychological harm. ‘Moderate harm’ means harm that requires a moderate increase in treatment — including an unplanned return to surgery or readmission, a prolonged episode of care, extra time in hospital or as an outpatient, or transfer to another treatment area such as intensive care — and is significant but not permanent. A tenfold insulin overdose needing intravenous glucose, a glucose infusion and extended monitoring is likely to meet that threshold; the decision is the trust’s. The provider must then notify the patient in person as soon as reasonably practicable, give an account of the facts known, say what further enquiries are appropriate, apologise, keep a written record, and follow up with a written notification containing the same and the results of any further enquiries. The CQC can prosecute a breach of regulation 20(2)(a) and 20(3). The DHSC’s review of the statutory duty (call for evidence April 2024; no outcome published that I could confirm) had not, as far as can be confirmed, produced a change to regulation 20 at 16 October 2026 — check before teaching. The Public Office (Accountability) Bill (the ‘Hillsborough Law’) was still before Parliament in July 2026; it would create a separate duty of candour on public authorities and officials in dealings with inquiries and does not replace regulation 20.
5. Reporting the incident: record it on the trust’s electronic incident-reporting system (Good medical practice paragraphs 45 and 73; candour guidance paragraph 24), which feeds the national Learn from Patient Safety Events (LFPSE) service — the NRLS was decommissioned on 30 June 2024. Incidents are reviewed under the Patient Safety Incident Response Framework (PSIRF, published 16 August 2022, replacing the 2015 Serious Incident Framework), which focuses on system learning rather than individual blame. The patient should be told that the incident has been reported and will be reviewed, and should be told the outcome. Commercial incident-reporting software is often known by its brand name; use the trust’s own term with patients, never jargon.
6. ‘Never events’: the NHS England Never Events list (January 2018, the current list at the time of writing; the framework was consulted on in 2024 and NHS England announced a ‘discovery phase’ for a new approach in September 2025) includes ‘overdose of insulin due to abbreviations or incorrect device’ — a tenfold or greater overdose because the words ‘unit’ or ‘international units’ are abbreviated, in a care setting with an electronic prescribing system; or failure to use an insulin syringe or pen; or withdrawing insulin from a pen with a syringe. A plain transcription error (80 for 8) on a paper chart is not within that definition — but it is the same hazard the 2010 NPSA Rapid Response Report ‘Safer administration of insulin’ addressed: write ‘units’ in full, never ‘U’ or ‘IU’; use a dedicated insulin chart; check the dose against the patient’s own account; and query any dose that looks unusual. Patients are the last line of defence — Mrs Tomlinson’s “that’s a lot” should have stopped the dose.
7. Treating the hypo (JBDS-IP 01, ‘The hospital management of hypoglycaemia in adults with diabetes mellitus’, revised January 2023): hypoglycaemia is a blood glucose below 4.0 mmol/L — “4.0 is the floor”. For an adult who is unconscious, fitting or unable to swallow: if intravenous access is available give 100 mL of 20% glucose (over 15 minutes, at 400 mL/hour) or 200 mL of 10% glucose (at 800 mL/hour over 15 minutes) — confirm the volumes and rates against the current JBDS-IP text; if not, 1 mg of glucagon intramuscularly (less effective in people on sulfonylureas, with liver disease or after repeated use; it may take up to 15 minutes to work). Recheck capillary glucose after 10 minutes and repeat if still below 4.0. Once above 4.0 and recovered, give a long-acting carbohydrate (20 g; 40 g after glucagon). Do not omit the next due insulin — the dose about to be given is unlikely to be the one that caused the hypo — but review the regimen. This applies to routine hypoglycaemia; after an insulin overdose the next long-acting dose is reviewed by the diabetes team and may be reduced or withheld while the effect persists. Document the event; continue regular capillary glucose monitoring for at least 24 to 48 hours.
8. Why the checks and the infusion continue: JBDS-IP 01 — if the hypoglycaemia was caused by a sulfonylurea or a long-acting insulin, the risk may persist for up to 24–36 hours after the last dose (longer with renal impairment), and these patients may need a continuous glucose infusion to maintain their blood glucose (10% glucose at 100 mL/hour is the JBDS example for those who are nil by mouth). Insulin glargine at therapeutic doses acts for about 24 hours; after a large overdose hypoglycaemia can be much more prolonged, and case reports describe glucose requirements for two to four days. So: hourly checks while the infusion runs, the diabetes team to decide tonight’s insulin (which may be reduced or held) and when to stop the infusion, and a second person to check any dose given.
9. Complaints: every NHS patient has the right to complain, and complaining must not affect their care (Good medical practice paragraph 46). Routes: the ward sister or matron; the trust’s Patient Advice and Liaison Service (PALS), which gives confidential advice and support and can resolve problems informally; or a formal complaint to the provider, or to the commissioner (the integrated care board). The doctor’s job is to explain the routes and support the patient, not to deflect; the daughter can complain on her mother’s behalf with her consent.
10. Confidentiality and the daughter: Mrs Tomlinson has capacity and decides what Debbie is told; the FY2 offers to speak to Debbie with her, or with her consent. If a photograph of the chart has been taken, that is the patient’s information about her own care; the trust’s information governance team can advise, but it is not a reason to be defensive.
11. Looking after the doctor: an error that harmed a patient is distressing for a foundation doctor; the GMC expects reflection, not concealment — discuss it with the educational supervisor, record a reflective entry (the foundation e-portfolio), take part in the review, and use support (the BMA’s counselling line 0330 123 1245, NHS Practitioner Health) if needed. A clearly documented, honest apology and a prompt incident report are also the best protection for the doctor.

Where candidates lose marks at this station

• “There was a bit of a mix-up with your sugars.”
• “The nurse should have checked.”
• “Sorry you had a rough night” — an apology that is not one.
• “It will never happen again.”
• Not knowing why the drip and the hourly checks continue tonight.
• Talking her daughter out of complaining.

Guidelines for this station

• GMC and NMC — Openness and honesty when things go wrong: the professional duty of candour (2015, updated 2022 and 2024)
• GMC and NMC — Being open and honest with patients when things go wrong: when to speak, what to say, saying sorry
• GMC — Good medical practice (2024), Domain 2 (paragraphs 45–46: being open if things go wrong; complaints)
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulation 20 — duty of candour
• Compensation Act 2006, section 2 — apologies, offers of treatment or other redress
• JBDS-IP — The hospital management of hypoglycaemia in adults with diabetes mellitus (revised January 2023) and other inpatient guidelines
• NHS England — Learn from Patient Safety Events (LFPSE) service
• NHS England — Patient Safety Incident Response Framework (PSIRF)
• NHS England — Never Events list 2018 (item 6: overdose of insulin due to abbreviations or incorrect device)
• NHS — What is PALS (Patient Advice and Liaison Service)?

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-33