Finding into death of Kylie Anne Lightfoot
Deceased
Kylie Anne Lightfoot
Demographics
24y, female
Coroner
Coroner Peter White
Date of death
2007-05-08
Finding date
2013-12-20
Cause of death
diabetic ketoacidosis in the setting of diabetes mellitus
AI-generated summary
Kylie Anne Lightfoot, a 24-year-old woman with type 1 diabetes, died from diabetic ketoacidosis. She presented to Dr Selvan's practice on 4 May 2007 with abdominal pain, having not checked her blood sugar or taken insulin that day. Dr Selvan's glucometer was broken, so she instructed Kylie to return home and check her blood sugar herself, giving oral instructions the coroner accepted as given. A urine dip test was negative for ketones. While the coroner accepted Dr Selvan did not have evidence of ketoacidosis at that consultation, the evidence suggests Kylie developed it afterwards. Key clinical issues: Dr Selvan failed to arrange appropriate follow-up contact, did not keep adequate medical records, and lacked a functioning glucometer. The coroner found questionable practice management but could not establish causal connection between her failures and death. Better practice would have included explicit documented instructions and follow-up telephone contact to verify Kylie had safely managed her insulin.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to arrange follow-up after clinic consultation
- broken glucometer at practice preventing blood sugar testing
- inadequate medical record-keeping
- lack of documented instructions to patient
- patient not taking insulin on day of presentation
Coroner's recommendations
- General practitioners managing diabetic patients should ensure they have a functioning glucometer available
- Explicit follow-up contact should be arranged when a diabetic patient is sent home to self-manage blood sugar testing
- Clear and documented instructions should be provided to diabetic patients attending medical consultations
- Medical records should document results of investigations such as urine dip tests
- Clinicians should maintain awareness of a patient's specialist care and communicate with specialists when managing acute presentations
Full text
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