Coroner's Finding: Earl, Kathleen May

58y · Female·Complications of poorly controlled type 2 diabetes

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.