Before HM Coroner James Dillon at Canterbury Coroner’s Court. Narrative conclusion handed down on 11 September 2019.

Rory Badenoch, instructed by Girlings Solicitors, represented the family of the Deceased, Rosie Jean Umney, at a 2-day inquest into the circumstances of her death from diabetic ketoacidosis on 3rd July 2018. The Coroner concluded that Rosie’s death was contributed to by neglect following a GP’s failure (at an appointment the previous day): (i) to comply with NICE guidelines NG18 (diabetes type one and type two in children and young people) and NG51 (dealing with sepsis) and arrange immediate hospital attendance, and (ii) to undertake any independent blood sugar or urine ketone measurements.

Narrative Conclusion

Rosie Jean Umney died on 3rd July 2018 at Queen Elizabeth the Queen Mother Hospital in Margate to which she had been admitted by emergency ambulance during the early hours of the morning. It was established that she was in a state of advanced Diabetic Ketoacidosis. Her position was not retrievable and she passed away in hospital. There is evidence that she was non-compliant with the monitoring and treatment regime for her diabetes including that her blood sugar meter may not have been used for some days prior to the 2nd July. Rosie attended her GP surgery on the afternoon of the second of July. The GP did not send her to hospital, guidelines including those issued by NICE would have led the GP to send Rosie to hospital. The GP did not conduct any independent blood sugar or urine ketone measurements. To the extent therefore that the GP did not arrange immediate hospital attendance or undertake any independent blood sugar or urine ketone measurements I make a finding of neglect.”

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