Inquest into the death of Steven Thelander

29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)

Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy but was described as able to 'self-manage' his diabetes 'with supervision'—a characterisation that proved dangerously inaccurate. Critical failures included: lack of independent capacity assessment for diabetes management; insufficient clinical oversight by support workers who lacked understanding of diabetes pathophysiology; failure to escalate non-compliance with blood sugar monitoring despite recorded high readings (BSLs >20) and a low reading of 2; inadequate diabetes management plan from his GP; and no weekly meal planning despite dietary concerns. The trial sleepover revealed dangerous BSL variability but prompted no action. Escalation of warning signs in the final days was not acted upon. With appropriate clinical support, intervention, and escalation on 14 January would have offered ~95% survival chance.