Megan Davison
15 Jul 2024 · Coroner Alison McCormick · Hertfordshire
The coroner's concerns
1. lack of formal diagnosis for T1DE and treatment pathway for DKA
“there is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for Diabetic Ketoacidosis (DKA), an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm - there being a physical protocol, but no mental health protocol, for DKA”
2. lack of integration between mental health and physical healthcare systems
“Lack of integration between mental health and physical healthcare systems”
3. absence of recognised diagnosis for T1DE and pathways of care for T1DE and DKA
“Absence of a recognised diagnosis for Type 1 Diabetes with Disordered Eating (also known as T1DE) and absence of pathways of care for T1DE and Diabetic Ketoacidosis (by way of physical and mental health protocols)”
4. lack of consolidated records and direct communication systems
“Lack of consolidated records and direct communication systems between different parts of the healthcare system”
5. lack of record sharing with private providers such as The Priory
“record sharing which includes private providers would help to prevent future deaths”