A devastated sibling has shared the heart-wrenching tale of her brother's sudden death at 35 due to unchecked diabetes after a critical medical letter was mistakenly sent to the wrong GP surgery.
Jonathan Cunningham, who had an established mental health condition, was put on new medication during his stay at a private hospital. Upon his release, the hospital staff sent out an urgent note to his GP requesting his Type 1 diabetes be closely supervised as the new pills could potentially impact his blood sugar levels.
But the vital letter was delivered to an incorrect clinic, and even though healthcare providers from the mental health sector gave Jonathan's GP updates about his rising blood sugar readings, there was no follow-up. Blackburn-born postman, Jonathan, tragically died on April 20 in 2022 due to diabetic ketoacidosis when his blood sugar spiked to double the lethal threshold.
According to the NHS, diabetic ketoacidosis typically affects people with type 1 diabetes, but can happen in those with type 2 diabetes who need insulin. It is a serious condition where a lack of insulin can cause harmful substances like ketones to build up in the blood.
Speaking at this month's inquest at Preston Coroner's Court, Area Coroner Kate Bisset concluded: "Jonathan Samuel Cunningham died on the 20th April 2022 at his home address as a result of diabetic ketoacidosis. Mr Cunningham had a complicated physical and mental health history which included diabetes and mental illness."
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"In March 2022, Mr Cunningham started a new medication for his mental illness which has known side effects for diabetes control. That medication was started whilst Mr Cunningham was an inpatient in hospital but discharge letters notifying his general practitioner of the need for close monitoring of his diabetes were sent to the wrong practice.", reports Lancs Live.
"Mental health workers raised concerns about Mr Cunningham's diabetes control but due to administrative errors, these were not known to his general practitioner and so no monitoring of his diabetes took place despite high blood readings. His diabetes was therefore uncontrolled at the time of his death."
Jonathan's sister Carrie Ann, also from Blackpool, said that "something has got to change" in supporting people to control their diabetes.
"It's absolutely devastating what happened to my brother," she said. "He was only diagnosed in 2021 after having suffered a near-fatal diabetic ketoacidosis and he was only 35 when he died of diabetic ketoacidosis a year later."
"We only discovered from his post-mortem that he had been misdiagnosed as Type 2 and was actually Type 1. It's horrendous how people are being let down and something has got to change."
"I am in no doubt that my brothers death was preventable, he was supposed to be under very close monitoring for a few reasons and his ketones in his toxicology report were almost double what is considered fatal."
The NHS said symptoms of diabetic ketoacidosis include:
- feeling thirsty
- needing to pee more often
- stomach pain, feeling sick or being sick
- diarrhoea
- breathing more deeply than usual
- breath that smells fruity (like pear drop sweets or nail polish remover)
- feeling tired, sleepy or confused
- blurred vision
The symptoms usually develop over 24 hours, but it can be faster. The condition can be life-threatening and needs urgent treatment in hospital.
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