Finding into death of Beryl Eileen Brindley

74y · Female·Diabetic ketoacidosis

A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating insulin doses. Critical failures included: inadequate monitoring of vital signs and ketones; lack of 'sick day' management protocols; no blood ketone testing despite recommendation; poor documentation of clinical assessments; and crucially, failure to ensure timely hospital transfer despite medical deterioration. The patient refused transfer on three occasions, but experts found her decisional capacity was impaired by severe hyperglycaemia (BGL >15 mmol/L causes cognitive changes). No doctor personally assessed her to discuss risks or confirm her competence. Earlier recognition of the deterioration pattern, implementation of sick day guidelines, and proactive escalation with formal capacity assessment could have enabled life-saving intensive care treatment.