Finding into death of Caleb Harley Pearson

17y · Male·Diabetic ketoacidosis

Caleb Pearson, a 17-year-old with undiagnosed Type 1 diabetes, presented with pharyngitis and was diagnosed and treated for a throat infection by his GP on 25 May 2015. Over the following two days he deteriorated with vomiting, lethargy and inability to move. Paramedics attended on 27 May evening and found him with tachycardia (120 bpm), tachypnoea (40 bpm), hypothermia and signs of dehydration, but attributed his presentation to anxiety and upper respiratory infection. They did not take a blood glucose level or transport him to hospital. He died from diabetic ketoacidosis (DKA) six hours later. The coroner found his death was preventable: the significantly abnormal respiratory rate alone warranted hospital transfer for investigation. Paramedics failed to recognise the constellation of vital sign abnormalities as indicative of serious illness, were influenced by cognitive bias from the recent GP diagnosis, and did not perform basic investigations like blood glucose testing that might have identified DKA.