Coroner calls for better T1DE care after Herts teacher dies

Megan Davison, 27, died in August 2017. Prior to this, she was suffering from diabulimia - a combination of type-one diabetes and disordered eating, now more accurately known as T1DE.

An inquest in March 2018 concluded the cause of Megan’s death was suicide.

However, Megan’s family were unhappy that the inquest did not investigate the treatment she received for T1DE. They instructed specialist public law and human rights lawyers at Irwin Mitchell, who successfully applied to the High Court to quash the first inquest and order a second hearing.

Her family have now spoken out after the second inquest concluded that Megan died by suicide in the context of T1DE.

Megan suffered from T1DE - a combination of type-one diabetes and disordered eating. (Image: Courtesy of Irwin Mitchell)

Assistant coroner for Hertfordshire, Alison McCormick, issued a Prevention of Future Deaths report, calling on the government to set out what action it will take to improve patient care.

It comes after the coroner raised concerns that, on a national level, there is no system capable of being operated in a way to ensure proper integrated healthcare for patients with T1DE.

She said: "There is no formal diagnosis for T1DE, no treatment pathway for T1DE and no complete treatment pathway for diabetic ketoacidosis (DKA) - an acute clinical emergency associated with T1DE caused by deliberate omission of insulin, which should be seen as an act of self harm."

Other issues raised as making more than a minimal contribution to Megan’s death included her discharge from the care of a mental health trust, a lack of integration between physical and mental healthcare systems, and a lack of consolidated records and communication between different parts of the healthcare system.

Megan’s mum, Lesley, said: "It’s impossible to find the words to describe the pain we’ve felt since losing Megan. There isn’t a day goes by when we don’t miss her. Our daughter was a very special and much-loved individual.

"We’re so grateful that we were granted this second inquest so that Megan’s condition could be investigated sufficiently. While it doesn’t change what happened, and the hearing has again been tough to get through, we now have some answers to the questions we’ve been asking for seven years.

"We’re also thankful that a national Prevention of Future Deaths report has been issued to the Secretary of State for Health. While it’s sadly too late for Megan, we hope that this will go a long way in helping others living with T1DE.

"All we can hope for now is that by speaking out we can help raise further awareness of the condition so that others don’t suffer like Megan did."

Megan was just 27 when she died. (Image: Courtesy of Irwin Mitchell)

Oliver Carter, the lawyer representing Megan’s family, said: "This is a truly tragic case, and Lesley and Neal have spent the past seven years struggling to come to terms with losing their daughter, but also using their considerable energy and experience to try to save the lives of other people with T1DE.

"The pain and grief Megan’s loved ones feel has understandably been made worse by their wait for a second inquest. While reliving everything again at the hearing has been upsetting, it’s something they had to do to honour Megan’s memory.

"Nothing will ever change what’s happened or bring Megan back, but we’re pleased that we’ve at least been able to provide Lesley and Neal with the answers they deserve.

"It’s now vital that lessons are learned to reduce the risk of others going through what Megan did and, as a result, we welcome the coroner’s decision to issue a Prevention of Future Deaths report to improve patient safety."

The Secretary of State for Health and Social Care, and Hertfordshire and West Essex Integrated Care Board, must respond to the coroner’s report by September 9, setting out the action they plan to take in response to the coroner’s concerns.