Herefordshire Council has admitted that failings were made that led to the death of a seventeen year old boy with type 1 diabetes.
The boy, referred to as HH, was known to be homeless and struggling with control of his type 1 diabetes, which ultimately led to his death from ketoacidosis. The failings are laid out in a 57 page serious case review into the teenager’s death.
HH’s case is very sad. He had come with his family to Herefordshire from Poland when aged 10 and was diagnosed with type 1 diabetes aged 16. HH’s mother had not involved herself in the management of his diabetes and had told him to leave home within a year of his death.
Given HH’s vulnerability, he should have received a number of services as he was classed as a ‘Looked After Child’. The fact that he did not receive a number of these services, nor was he given a LAC care plan, was listed as one of a number of failings that occurred.
Amongst other key failings was confusion over whether HH should be treated as a child or an adult. In HH’s case, he had been treated as an adult whe, at 16 years old, he should have been treated as a paediatric patient. One of the consequences of this was that his mother had not been expected to be involved in the management of his diabetes.
In addition, the case review notes that the psychological impact of type 1 diabetes diagnosis during teenage years together with the neglect HH had suffered at home had not been adequately taken into account. HH had showed a number of signs of not having fully accepted his diagnosis as he would miss injections and at times would rarely use his blood glucose meter.
The serious case review concludes that the seriousness of type 1 diabetes needed to be better understood by the care agencies looking after HH. A number of recommendations feature at the end of the case review aimed at improving the level of care and preventing similar tragic cases from occurring in future.

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