An endocrinologist may have shied away from broaching the sensitive topic of fitness to drive with a diabetic patient who died in a car crash after experiencing a severe hypoglycaemic event, a coronial investigation has heard.
A Queensland coroner found that a 57-year old woman with type 1 diabetes had been noted by her [un-named] endocrinologist as having ‘unsafe’ diabetes for work purposes, but there appeared to have been no discussion about how this would affect her fitness to drive.
Crash investigators reported that her vehicle drifted off the road and hit a tree, consistent with loss of consciousness. Forensic investigation showed she had hypoglycaemia.
In his findings, Coroner James McDougall said fitness to drive could be a sensitive topic between doctors and patients, with records showing the woman had previously reported a suicide attempt after her driving licence had been suspended.
The coroner was advised that the barrier of difficult doctor-patient conversations around fitness to drive could be addressed by having an independent clinical service to assess drivers, as in Victoria.
The patient, Ms D, had been diagnosed with type 1 diabetes at the age of 20, and it was described as ‘brittle’ and unstable by her family, with a history of severe hypoglycaemic events. She required a medical certificate to hold a driver’s licence and her most recent one had been signed by her GP in December 2019, only four months before the fatal accident in March 2020.
Her diabetes was managed with an insulin pump and continuous glucose monitoring that should have provided alarm warnings of risk of hypoglycaemic events, according to a forensic physician. Data from her insulin pump showed she’d had 16 hypoglycaemic events in the month before the accident. Her husband said in evidence that he knew of only one incident in the preceding month.
The coroner said it was not clear why these incidents had not been reported or acted upon by Ms D, suggesting she had ongoing poor hypoglycaemic awareness.
“Ms D would have had to ignore at least 3 alarms from her pump prior to the development of her hypoglycaemic episode on the day of the accident,” the investigation was advised.
The forensic physician offered the opinion that the characteristics of Ms D.’s diabetes would have necessitated endocrinology input to determine her fitness to drive. However, her AFTD (assessing fitness to drive) certificate had been completed by her GP and signed off for five years instead of the recommended two years for people with insulin-treated diabetes.
“The history of severe hypoglycaemia as well as poor hypoglycaemic awareness would have likely made Ms D ineligible for a conditional licence, though this is ultimately up to the opinion of an endocrinologist as per the AFTD on diabetes. It is reasonable that the continuous glucose monitoring would negate the risk of hypoglycaemia,” the forensic physician said.
“I could find no evidence of discussions about safety to drive in the notes of the attending GP or the attending endocrinologist. This is concerning as the endocrinologist has previously complete paperwork to the effect that Ms D was unfit or potentially unsafe to work due to her diabetes, and yet driving does not appear to have been discussed.”
The coroner found, on the balance of probabilities, that Ms D. died as a result of the crash because she suffered a hypoglycaemic event and lost consciousness while driving.
Touching on the apparent failure of two treating doctors to address her fitness to drive, the investigation noted that: “Proximity in care of a patient and maintaining trust in a therapeutic relationship can mean such difficult subjects are not always broached to the full extent they could be.”
“One path around this apparent obstruction is identifying an independent clinical service to assess drivers. This is undertaken in the Victorian Institute of Forensic Medicine by Forensic Physicians.”