More interesting facts on Steven Kruegers death due to MMT-511 malfunction

I posted a blog on the w/e about Steven Krueger after coming across a news article that moved me quite emotionally. Since writing that blog - the family of Steven Krueger has come to me for help in trying to spread the word about Steven. Steven's death resulted in his pump going into PRIME function during his sleep - emptying out the WHOLE cartridge of insulin. Health Canada after investigating the pump stated his death was due to pump malfunction along with some other interesting facts (these cannot be disclosed at this point in time). Medtronics "had" agreed to do further investigations - stating that the pump case would have to be destroyed in order to do any testing. The pump left the coroners office in B.C., Canada - intact (pictures were taken prior to being sent off) - but a week later - Medtronic sent back the pump stating that the case was cracked - therefore they could not perform any tests!
This has all been going on over the past 3 years - not easy due to the two countries involved with our legal systems not being the same - very disheartening and frustrating to say the least - when the information that has been gathered could be of value to the public! The way things stand now - is Health Canada is hopefully going to do the further testing - and the final report can be written - but it will take time as we all can see from how it has gone so far.

The questions that have gone thru' my mind have been boggling (too many to list here - and I'm sure those that respond to this will have the same questions popping thru' their mind). The Krueger family doesn't want to any monetary reimbursement to the loss of their son - as some American friends seem to think - far from it - they just want closure - to know why the pump failed the way it did on Steven - and to hopefully prevent this from ever happening again.

Several other incidents causing patients' low blood sugar levels and three deaths have been reported of patients using this pump but again the pumps were never returned to the manufacturer for further investigation. As we all know mechanical devices fail at some time, however, they should fail in a safe mode rather than a lethal mode. It's just that if a car or plane crash was caused by a malfunction - then the manufacturer would follow up with an investigation so that they could pin point what caused it and warn the public - or rectify the situation so it wouldn't. Am I being naive here to think that companies think first about the cost of human life instead of profits and their stock holders?

I wonder if your pump manufacturer would do the same thing - and not follow up with an investigation (have already sent a letter to them asking them this question).

UPDATE: For additional discussion on this subject - please go to Christopher Frankie's discussion at this link.

I think you also have to consider this from the other side… if you experienced a similar pump failure that resulted in significant injury or death, would you automatically hand the pump over to the company responsible? I think that may be why the other cases were never investigated by Medtronic. I know I wouldn’t want to give them the only evidence I had. I actually applaud the Kreuger’s for just wanting to know what happened, with the hope of preventing it from happening again - not everyone in their position would be so selfless.

As far as Medtronic refusing to evaluate the pump because it was cracked - who are they kidding? If it was under warranty (I am assuming it was?) then wouldn’t they still be liable for ANY failure, whether mechanical or structural? If it was, I don’t think that should automatically get them off the hook either.

Yes, I am the same way as you. Here in Canada - the goverment first does their investigations - which is what happened in the case of Steven Kruegers pump. The Krueger’s would like to have a 3rd party investigation done in order to bring these other “interesting facts” - but Medtronic’s legal department back in June of this year (it’s taken a long time to bring this story out as you can see) has asked them not to reveal to the public at large. Unfortunately, this is a very expensive procedure to do - to have this type of investigation done. Their hopes now only rest with our own countires investigation to reveal the facts. These reports are public here in Canada - unlike other countries- where they maybe hushed up. It’s a long road for them.

Not sure if the pump was still under warranty. Am in the process of finding that out from the parents and other family members. One of the family members is a diabetic like myself - and because of Steven’s death - is very hesitant to go onto the pump. I don’t blame them at all! I have tried to reassure them - that they are safe - perhaps because of the MMT-511 causing other deaths - despite Medtronic not investigating it themselves - that what happened to Steven is a bizzare fluke and is something that now does not occur of the pumps they have on the market now. Still - to have closure to “what caused it” - is something I don’t think I could let go easily.

I really don’t think it matters whether the pump was under warranty or not.
I feel that Medtronic is still Liable. I wish the family would seek money
from Medtronic, That’s the only way to make them realize the magnitude
of what has happened. I am so fed up with Medtronic, with the infusion recall
and the way they are going about handling it. I can’t wait to purchase another
pump and get as far away from Medtronic as possible. They don’t give a damn about customers.
My sympathy to the Family, it’s very sad.

I only heard about this case last week, and no matter what caused the pump to malfunction, Medtronic/Minimed is liable for it as the manufacturer. The “cracked” part is right, Minimed is cracked if they believe this excuse is acceptable. They need to find out why this malfunction happened in the first place, rectify the situation, alert all Minimed pump users about this potential problem, and do something to make sure this never happens again. I’ve had some pump issues over the nearly 11 years I’ve been on a pump and it scares me. Fortunately, I’ve been on the other end, no insulin delivered.

Hopefully Minimed will rethink their position and step up to the plate to make this all right. I’m sure the Krueger family is trying to make sure their son didn’t die in vain, but hopefully their pressure will help other diabetics on pumps from becoming vistims of a unexplained malfunction.

Cara - this is the main reason for them wanting me to bring this to the attention of everyone - am working on getting it thru’ the media here in Canada (never done this sort of thing before - but darnit - am going to try my hardest to help). They just want to help other diabetics on pumps realise what happened to their son - and others (just had a very interesting PM from someone about the same MMT-511 pump basically doing something similar - emptying the whole cartridge into him - BUT HE WAS AWAKE - I’ll ask for permission from him before posting his story - very scary nevertheless).

I guess it’s being Canadian - no offense to Americans - but we don’t tend to be the sue for money type - I don’t even think we know how to! Must be the cold climate up here - effects our brains or something. Most Canadians will apologise to someone who has hit them (e.g. walking down a street - and you’re elbows bump ). We are generally pretty polite and try to not cause commotion. I am going over and beyond my comfort level here in writing about things like this - but it’s giving me a good feeling knowing that I am trying to help out the Krueger family - to bring some sort of closure for them and making people aware (I mean - would my pump company turn a blind eye if something happened with one of their pumps - have sent a letter to them asking this question).

I am in the process of finding a website for getting a petition going - so far have coming across this website - but if any of you know of something better - that may gain more attention - feel free to post it here - or PM me. Again, I’m a newbie here at Tudiabetes - never been really one for posting in forums until I started pumping insulin. In school - used to not get involved in discussions even tho’ I wanted to put my point in. I’m better at writing then verbally speaking as you can see (most of the time - except when I type in a hurry like I am here - as I’m supposed to be working on dinner - duh - poor hubby is so understanding with me).

Hi Dave - do you work for Medtronic Corporation with a statement like that?

Not sure if you know the cause of Steven’s death - but his pump went into PRIME mode during his sleep time - not sure if it’s possible to roll around in the bed - and set off the right keys to get the pump to go thru’ these steps back in 2007 when Steven’s overdose occurred. There are other things that occurred that Health Canada coronors office came across - but Medtronic won’t allow that information to be released to the public at this point in time.

Someone wrote to me - offboard saying they had a similar experience - but during their waking hours thankfullyl. They had already filled up their insulin cartridge that morning with 160 units - had bolused for their lunch with 20 units. Not long after their lunch bolus, they felt the pump vibrate. When they looked at their pump it said RESERVOIR EMPTY. Their pump had just emptied their entire insulin reservoir of 140 units or 1.4 ml into their body. This a done within a 5 minute time frame! They manage to get help right away - and recovered with help of ALOT of food!

They say that later on when they tried to reload the pump with new insulin into the reservoir - it wasn’t possible because every time they tried to Prime it, by holding the ACT button, it wouldn’t stop priming! It just pushed all the insulin out and primed till it was empty. They even tried holding the plunger mechanism down with the eraser end of a pencil and it continued to push it’s way past the pressure that they were were exerting against it with the pencil.

After speaking to MM and telling them what happened - they sent them a new pump the next day - but they never found out what exactly caused the problems they’d experienced that day. This occurred about 3-4 years ago (they couldn’t remember the exact date).

So, yes Dave, 3-4 years ago makes a big difference in how our pumps work today! Just a few people got bumped off our big blue marble in the process without any explanation by the manufacturer why their pump malfunctioned. Ahhh, isn’t it grand being a human guineau pig … NOT!!!

Is there a way to hand deliver the “cracked” pump to a different source, such as an engineering company, a computer company or some sort of scientific place to get the help to determine what caused the pump to malfunction? I am thinking a technical facility or computer manufacturer may have some sort of insight. I would suggest this step to the family instead of going back to Medtronic to get an independent study of the issue resulting in their son’s death.


“The usual cause for severe hypoglycemia when using a pump or MDI therapy is failure on the part of the patient to choose the proper dosage, or failure to monitor bg’s on a timely basis”

I guess it technically isn’t inaccurate, just irrelevant to the discussion at hand in which a MINIMED pump killed someone because it went into PRIME mode. This poor kids death had nothing to do with “failure on the part of the patient to choose the proper dosage, or failure to monitor bg’s on a timely basis”

I think it also has something to do with some of the other comments you have left in other forums that would lead one to think you work for MM. I dont want to sound like jerk about it, because you also write a lot of great advice for people in the forums too.

oh come on dave, what would internet forums be without using broad paint brushes?? :wink:

Okay - paint brushes aside since I only do finger painting myself!

I just found out from Steven’s Mum that he had only had his pump for 3 years and a few months. So, Dave - this means his pump would have been under warranty I hope! I know my pump - Animas 2020 has 4 years warranty - I think that’s the standard. Still waiting from them as to what they would do in a situation like Steven’s - but no word back yet.

Catherine - the cost of a 3rd party is beyond what the Kruegers can afford. As I had written previous - the pump had been investigated by Health Canada - and it was determined what the problems were that had occurred with the pump - unfortunately the Kruegers due to legalties are not allowed to reveal all of Health Canada’s findings to the public due to legal issues with the company. Understandable in some ways - as they are trying to protect themselves - but doesn’t the public have the right to know? Especially for those who are still using the MMT-511 model (and according to one of my inside sources - there are many still being used) - which may or may not be a time bomb waiting to explode so to speak.

Mian thing is like Dave has pointed out there are a few issues with Medtronic pumps (as I’m sure there are with others - but haven’t heard anything with my Animas … yet). Apologies to you Dave - I didn’t realise you had written about problems with MM Medtronic - I’m a newbie to forum posting - so obviously have ALOT of catching up to do.

Like I keep on saying - MM Medtronic makes a product that is used by millions, and has given freedom to those wearing the pump. It’s just the frustration for the Kruegers of their lack of response and caring. As I keep on saying (feel like a tape on rewind LOL) a large corporation and money is the name of the game. The Kruegers DO NOT WANT ANY MONEY - it will not bring Steven back. Like the Kruegers said to me - what would they do with the money? It would so go against anything that Steven, their son stood for. From the way the Kruegers have described Steven - and this is perhaps why I feel so close to trying to spread the word to everyone is that he was, and I quote - " there for the underdog, the homeless guy on the street, the unpopular person and so he would want us to pursue this in a positive way, and that is what we are trying to do. " He is alot like me in my principles - and I feel almost like he’s looking over my shoulder saying “Keep on keepin’ on!!!”

Anyway, many thanks for those of you PMing me - some are going way out for me in spreading the Kruegers story - and they thank you from the bottom of their hearts. This is one great community - I think the best I’ve come across so far besides Diabetes1!

What a horrific story! Minimed is legally liable and should be sued. No, I would NOT return the pump to Minimed for evaluation. I would hire a lawyer, even if I did not wish a monetary settlement. I would donate the settlement to a good cause. I feel if Minimed has to pay a hefty settlement, that would be a deterrent and they would be more careful with inspecting pumps. I have read of one other instance, but the child was brought to the ER and survived. The pump that malfunctioned on the teen was a Paradigm. Worried now, as DN has a Minimed pump.

P.S. I don’t remember if the pump primed all the insulin in to the teen, but there was an overdose of insulin.

And for the Segway! :slight_smile:

(sorry, couldn’t help it…)

Dave - I had to look up who this Dean Kamen was - for those of you who maybe like me - here’s an explanation - Wonder if he still lives in NH - that’s just a hop and a skip from Montreal?
Sarah - I saw a group of people on Segway’s when I was in D.C. back in June. They looked like alot of fun. Guess they were doing the tour of the city on them - to save them from legging it all over the place like we were doing (burned up lots of calories - but I used about 50% less insulin over the 4 days we were visiting there).


Applauding your efforts. Keep on fighting the good fight for Steven & his family. Admire his parents for wanting to address this in a positive way. Don’t think I’d be as civilized given Minimed’s attitude.

Dave - As my boss at Diabetes1 said to me last night - and here I was thinking I was going to get booted out the door because of what I am doing - he wrote - “Opinions are essential to free speech!” and quoted Voltaire (never had heard of this dude before) - " I may not like what you say, but I will fight to the death for your right to say it. "

My note on the side : insulin is a dangerous drug if not used with care …overdosing manually , by pump or by failure of pump …I was taught to have a Glucagon kit for the treatment of hypoglycemic reactions on hand at all times and have someone available to administer , when required .This may not always work in reality , however if has given me some comfort .

i too am constantly refilling my glucagon Rx, even though I have NEVER used it in my 18 yrs of d-life – had some pretty close calls though.

I’m thinking about the story told earlier in the thread of the person who had a reservoir empty into them while they were awake and were able to be treated. I have a cozmo, with a reservoir of 300ml. I also probably use a lot less insulin than the other person – about 30 units a day. I think I would probably need several glucagon shots to survive that much insulin at once.

Thanks Nel and Dave for reminding me to ask my doctor for an RX when I see him in a few weeks. I’ve never had a Glucagon kit. I know my parents had one when I was a child - I can’t remember if they had to use it on me - but they always kept one. I left home at 18 (had enough of Mum and Dad LOL) - and never thought of keeping one. I think since joining up to Tudiabetes - and being older and wiser (not sure about that bit) - I am relearning some things about diabetes. We’re in the process of planning an 18 day cruise in the Grenadines this Jan - so with how the sun/heat effect me - I think that kit will be a NECESSITY OF LIFE for me - whether or not it gets used. Will check for the expiry date Dave!!