Unusual problems for the physician in managing a hospital patient who received a malicious insulin overdose.

A patient recovering normally from a biopsy and subtotal removal of a malignant brain tumor became severely hypoglycemic on the ward and died. The differential diagnosis eliminated disease as a possible cause, and medication error on the floor was also ruled out. Deliberate administration of a massive dose of insulin intravenously seemed to be the only alternative. A careful investigation supported the likelihood of a criminal act. The patient's wife came under suspicion and was subsequently arrested, charged with murder, and convicted. This sequence of events created three problems that fell outside of our normal professional training and experience as physicians. First, we were slow to suspect foul play in our search for an unusual cause. Second, the steps taken to protect the patient against further risk without denying reasonable rights to family or arousing the suspect's suspicions needed strengthening. Third, even though the occurrence of these events in a hospital allowed an unusual degree of evidence documenting the allegations to be accumulated, key parts of the evidence could not be used. The routine hospital handling of laboratory tests critical to support of the accusations was not sufficient to meet the demands of the legal system, which has its own criteria. We discuss the issues in managing these problems.