Finding into death of Phillip John Sealey

62y · Male·Diabetic ketoacidosis in a man with coronary atherosclerosis and cardiomegaly

Phillip Sealey, 62, presented to his local GP on 27 June 2019 with three weeks of thirst, urinary frequency, nocturia, blurred vision, dizziness and vomiting. The GP diagnosed hypertension and suspected diabetes mellitus, ordering blood tests for the following day. No point-of-care glucose testing was performed despite classic symptoms of hyperglycemia. Phillip deteriorated rapidly at home that evening with altered mental status and died from diabetic ketoacidosis with concurrent coronary atherosclerosis. The coroner found that performing a fingerprick glucose test might have identified severe hyperglycemia, prompted ketone testing, and enabled earlier hospital referral. However, given Phillip did not appear 'grossly unwell' on examination and lacked typical DKA features (abdominal pain, tachycardia, hypotension), no adverse findings were made. The case highlights missed opportunity for point-of-care testing in a patient with classic diabetes symptoms presenting outside hospital.