Inquest into the death of Steven Thelander

Contributing factors

• Severely impaired intellectual functioning due to cerebral palsy; inability to self-manage diabetes
• False characterisation that Steven could 'self-manage' his diabetes 'with supervision'
• Lack of independent capacity assessment prior to placement
• Inadequate understanding by Multicap support workers of diabetes pathophysiology and severity
• Insufficient clinical oversight and nursing support for blood sugar monitoring and insulin management
• Failure to escalate non-compliance with blood sugar monitoring despite clear warning signs
• Trial sleepover (18–20 Sept 2017) showing dangerous BSL variability (readings of 24, 20, and 2) did not trigger placement review
• Inadequate diabetes management plan from GP (Dr Brockman) dated 16 October 2017
• Lack of weekly meal planning despite mother's dietary recommendations
• Failure to escalate high BSL readings (>13.3 mmol/L) in final days despite supervisor and worker concerns
• Missing clear emergency response protocols for hyperglycaemia
• Lack of communication and escalation between support workers, supervisors, and managers
• No attendance at dietician appointment (11 January 2018) by support worker
• Absence of specialist endocrinology referral despite unstable diabetes control (HbA1c 8.9–9.1%)

Coroner's recommendations

1. Multicap should review promotional material to clarify specifically what services will and will not be provided, with detailed examples, particularly for 'high needs disability support'
2. Multicap should prepare a formal response plan or procedure for circumstances where a client lacks capacity but declines or refuses to comply with a care plan or regime necessary for life; the plan should detail appropriate responses for support workers, supervisors, and managers