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Coroner's Finding: Earl, Kathleen May

Deceased

Kathleen May Earl

Demographics

58y, female

Date of death

2022-06-23

Finding date

2024-10-23

Cause of death

Complications of poorly controlled type 2 diabetes

AI-generated summary

Ms Kathleen Earl, aged 58, died from complications of poorly controlled type 2 diabetes in June 2022. She had an intellectual disability and received support from IHCS (Individual Support Worker) since 2005. Critical deficiencies included: no ISW visits for 7 months before death; no home monitoring of her diabetes despite demonstrated inability to self-manage; irregular contact with her support organisation; and failure to maintain regular attendance at diabetes clinic. Her GP correctly identified poor diabetic control on 10 March and 6 June 2022 but did not re-refer to specialist clinic or escalate care. IHCS terminated her regular ISW in February 2022 citing inability to find suitable replacement, providing no alternative support despite contractual obligation for fortnightly visits. No welfare checks occurred despite prolonged communication gaps. Clinically, aggressive diabetes management, regular ISW-facilitated clinic attendance, home glucose monitoring, and proactive medical escalation could have prevented this death.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practiceendocrinology

Error types

systemcommunicationdelay

Drugs involved

ryzodegdoxylamineparacetamoldosulepintramadolrosuvastatin

Clinical conditions

type 2 diabetes mellitus (poorly controlled)insulin-dependent diabetes mellitusdiabetic ketoacidosishyperglycaemiahypoglycaemiachronic kidney diseasemedullary sponge kidneypyelonephritisintellectual disabilitypost-traumatic stress disorderdepressionanxietyinsomniachronic painhypothyroidismgastro-oesophageal reflux disease

Contributing factors

  • Poorly controlled insulin-dependent type 2 diabetes with blood glucose levels in 20s
  • Inability to self-manage diabetes despite intellectual disability
  • Absence of regular support worker from November 2021 until death
  • No home visits for 7 months prior to death
  • No welfare checks despite prolonged contact gaps
  • Failure to re-refer to diabetes specialist clinic despite documented poor control
  • Inadequate monitoring of blood glucose levels
  • Difficulty using insulin pen correctly
  • Previous misreporting of blood glucose levels in diary
  • Medullary sponge kidney and chronic kidney disease
  • Pyelonephritis of right kidney
  • Elevated acetone levels indicative of diabetic ketoacidosis
  • Social isolation and limited family contact
  • Living alone with minimal support network

Coroner's recommendations

  1. IHCS to implement mandatory administrative checks to identify clients without documented service for periods of one month with required follow-up
  2. IHCS to establish formal policy for withdrawal as service provider when services refused indefinitely or unable to be provided
  3. IHCS to implement designated 'Individual Service Coordinator' role for all clients with clear communication of responsibility and accountability
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.