BEUDAMED
    FDA Adverse Event Death Summary report: N

    630G INSULIN PUMP MMT-1715K 630G BLACK MG

    MDR report key: 15038067 · Received July 18, 2022

    Report

    Report Number
    2032227-2022-288286
    Event Type
    Death
    Date Received
    July 18, 2022
    Date of Event
    May 3, 2018
    Report Date
    July 16, 2022
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    OZO
    UDI-DI
    00643169656840
    Removal / Correction Number
    Z-0955-2020
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IL, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 0

    THIS REPORT IS PART OF A RETROSPECTIVE REVIEW AND REMEDIATION EFFORTS IN RESPONSE TO A WARNING LETTER. Z-0955-2020. (B)(4). PUMP RECEIVED NOT STUCK IN THE MANUFACTURING MODE. S/W 2.8C. PUMP PASSED THE FUNCTIONAL TESTS, INCLUDING THE SELF TEST, SLEEP CURRENT MEASUREMENT, ACTIVE CURRENT MEASUREMENT, REWIND TEST, PRIME/SEATING TEST, BASIC OCCLUSION TEST, OCCLUSION TEST, FORCE SENSOR TEST AND DISPLACEMENT TEST. PUMP RECEIVED WITH NO BATTERY INSTALLED. PUMP RECEIVED WITH SCRATCHED CASE, PILLOWING KEYPAD OVERLAY, CRACKED RETAINER AND MINOR SCRATCHED LCD WINDOW. DATA ANALYSIS: (B)(6) 2018 DAILY TOTAL OF ALL INSULIN DELIVERED = 35.425. (B)(6) 2018 DAILY TOTAL OF ALL INSULIN DELIVERED = 34.725. (B)(6) 2018 DAILY TOTAL OF ALL INSULIN DELIVERED = 34.725. (B)(6) 2018 DAILY TOTAL OF ALL INSULIN DELIVERED = 37.025. (B)(6) 2018 DAILY TOTAL OF ALL INSULIN DELIVERED = 37.825 .(B)(6) 2018 DAILY TOTAL OF ALL INSULIN DELIVERED = 34.725. (B)(6) 2018 DAILY TOTAL OF ALL INSULIN DELIVERED = 7. MEDTRONIC, INC. (MEDTRONIC) IS SUBMITTING THIS REPORT TO COMPLY WITH 21 C.F.R. PART 803, THE MEDICAL DEVICE REPORTING REGULATION. THIS REPORT IS BASED UPON INFORMATION OBTAINED BY MEDTRONIC, WHICH THE COMPANY MAY NOT HAVE BEEN ABLE TO FULLY INVESTIGATE OR VERIFY PRIOR TO THE DATE THE REPORT WAS REQUIRED BY THE FDA. MEDTRONIC HAS MADE REASONABLE EFFORTS TO OBTAIN MORE COMPLETE INFORMATION IN THE TIME ALLOTTED AND HAS PROVIDED AS MUCH INFORMATION AS IS AVAILABLE TO THE COMPANY AS OF THE SUBMISSION DATE THIS REPORT. THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OR A CONCLUSION BY FDA, MEDTRONIC, OR ITS EMPLOYEES THAT THE DEVICE, MEDTRONIC, OR ITS EMPLOYEES CAUSED OR CONTRIBUTED TO THE EVENT DESCRIBED IN THE REPORT. IN PARTICULAR, THIS REPORT DOES NOT CONSTITUTE AN ADMISSION BY ANYONE THAT THE PRODUCT DESCRIBED IN THIS REPORT HAS ANY ""DEFECTS"" OR HAS ""MALFUNCTIONED"". THESE WORDS ARE INCLUDED IN THE FDA 3500A FORM AND ARE FIXED ITEMS FOR SELECTION CREATED BY THE FDA, TO CATEGORIZE THE TYPE OF EVENT SOLELY FOR THE PURPOSE OF REPORTING PURSUANT TO PART 803. MEDTRONIC OBJECTS TO THE USE OF THESE WORDS AND OTHERS LIKE IT BECAUSE OF THE LACK OF DEFINITION AND THE CONNOTATIONS IMPLIED BY THESE TERMS. THIS STATEMENT SHOULD BE INCLUDED WITH ANY INFORMATION OR REPORT DISCLOSED TO THE PUBLIC UNDER THE FREEDOM OF INFORMATION ACT.

    Description of Event or Problem · 0

    IT WAS REPORTED VIA PHONE CALL THAT THE CUSTOMER PASSED AWAY AT HOME ON (B)(6) 2018. THE CUSTOMER WAS HOSPITALIZED ON UNKNOWN DATE. THE CAUSE OF DEATH WAS CONGESTED HEART AND STAGE 4 KIDNEY FAILURE. THE CUSTOMER¿S BLOOD GLUCOSE LEVEL WAS 108 MG/DL. THE CALLER ALSO STATED THAT THE CUSTOMER HAD CAME HOME ONLY 12 HOURS PRIOR TO PASSING AWAY. THE CUSTOMER WAS WEARING THE INSULIN PUMP AT THE TIME OF DEATH. THE INSULIN PUMP WILL BE RETURNED FOR PRODUCT ANALYSIS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2891516 630G INSULIN PUMP MMT-1715K 630G BLACK MG ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND OZO MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-1715K HG2ABGC 00643169656840

    Patients

    Seq Age Sex Outcome Treatment
    1 65 YR Female Death