Finding into death of Vincenzo Bellina

48y · Male·Septicaemia in a man with a psoas abscess; Diabetes mellitis

A 48-year-old man with insulin-dependent diabetes, mild cognitive impairment, and chronic alcoholic liver disease was admitted with sepsis from a psoas abscess. After 15 days of intravenous antibiotics, he refused IV continuation on 5 December. He was switched to oral antibiotics and discharged on 6 December, despite his parents' previous significant role in his medication management and daily support. Crucially, staff did not inform his parents of discharge because they believed he would contact them himself, though a nursing note documented him injecting insulin through his clothing—a concerning sign that was not flagged to senior clinicians before discharge. He died on 10 December from secondary opportunistic sepsis with bacteria unlikely sensitive to his prescribed antibiotic. The coroner found parents should have been notified of discharge, particularly given the critical importance of medication compliance and the undisclosed concerning clinical observation.