This case involves a seventy-nine-year-old male patient with a past medical history of very poorly controlled diabetes and resultant diabetic foot disease. The patient required daily supervision and was living with his daughter, who was his main carer at the time. The patient was receiving medical treatment a local hospital for gangrenous changes of the right foot. Conservative management was not successful and surgery was required to prevent further spread of the gangrene. The patient underwent a trans metatarsal amputation procedure and was transferred to an inpatient rehabilitation unit for further care. The procedure was deemed to be successful and the patient made a good recovery post-operatively. Shortly before being discharged, the patient was given a bolus of 15 unit of insulin by a nurse in the rehabilitation unit. The patient was transported home by his daughter. Shortly after arriving home, the patient complained of feeling unwell and went to bed. The daughter found the patient unresponsive in bed. He had no pulse and was not breathing. She initiated CPR and called for an ambulance. The patient was immediately transferred back to the hospital but remained in a critical condition after sustaining cardiopulmonary arrest. The patient never recovered and died following a long hospital stay.