Inquest into the Death of Halford

17y · Female·Multi System Failure following acute onset (Acute Diabetic Ketoacidosis) Diabetes Mellitus in a person with known Lipoatrophic Panniculitis

Lee Rebecca Halford, a 17-year-old girl, died of acute diabetic ketoacidosis (DKA) following undiagnosed Type 1 diabetes. She initially presented to a GP with vomiting on 27 February 2007, diagnosed with gastroenteritis. Despite three GP presentations and escalating symptoms, diabetes was not considered. The coroner found that while the gastroenteritis diagnosis was reasonable at the time given her presentation, DKA should have been considered as a differential diagnosis, particularly after multiple presentations with ongoing vomiting and an elevated pulse rate. Key factors included the family's misunderstanding of metropolitan ED admission processes, GPs not performing urinalysis or considering diabetes as a differential diagnosis, and failure to appreciate the severity of Lee's clinical deterioration. She deteriorated overnight and was found unresponsive on 28 February, dying in hospital ICU same day. The coroner recommended improved GP awareness of rapid-onset DKA in young people and greater use of urinalysis to detect diabetes.