Tragedy as man with diabetes dies after vital hospital letter sent to wrong GP surgery

A woman who lost her brother after his diabetes went unchecked following a hospital mistake has spoken of her devastation.

Jonathan Cunningham was started on new medication for an existing mental illness during an admission at a priory hospital.

When he was discharged, hospital staff sent a letter to the GP surgery requesting that his Type 1 diabetes was closely monitored due to the new medication potentially affecting his blood sugar levels.

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But the letter was sent to the wrong surgery, and even when concerns about Jonathan's high blood sugar levels were flagged up to his GP by mental health workers, no monitoring took place.

Jonathan, a postman who was born in Blackpool, died on April 20 in 2022 from diabetic ketoacidosis when his blood sugar rose to twice the level considered to be fatal.

At an inquest held this month 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.

"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.

"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, Lancs Live reports.

"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."