Inquest into the Death of Halford

Contributing factors

• Failure to consider diabetes mellitus as differential diagnosis despite multiple presentations
• Failure to perform urinalysis to detect diabetes
• Failure to appreciate severity of clinical deterioration over three presentations
• Elevated pulse rate not escalated to higher level of care
• Lack of documentation of vital signs including blood pressure and pulse at initial consultation
• Family's misunderstanding of metropolitan ED admission and triage processes
• Poor communication between GP and family regarding necessity of hospital admission
• Locum doctor's failure to explain consultation notes and warning signs to family
• Masking of dehydration by continued urine output despite developing DKA

Coroner's recommendations

1. This finding be sent to the Royal Australian College of General Practitioners to elevate general practice awareness of differential diagnosis of sudden onset DKA in young people
2. In view of rising incidence of diabetes in young people, GPs not overlook that the ability to pass urine may mask developing dehydration due to onset of DKA and use of urine sugar test may be a useful tool in diagnosis
3. GPs explain the unpredictability of ED admission times as a necessary factor in prioritisation of medical care while explaining benefits of access to specialist support in undiagnosed illness
4. GPs consider that when a patient has suffered an autoimmune condition in the past it may indicate a propensity to other autoimmune conditions