'It should never have happened': Devastated mum hits out after inquest finds neglect contributed towards son's death on 21st birthday New York trip

Shaun Dobinson, 21, from Porthcawl Drive, Washington, died on June 3, 2016, while visiting the American city.

Shaun was admitted to hospital and suffered multiple cardiac arrests.

The cause of death was found to be diabetic ketoacidosis leading to heart failure.

Diabetic ketoacidosis is a condition caused when the body runs out of insulin.

A three-day inquest into Shaun’s death was held at Sunderland Coroner’s Court this week where Senior Coroner, Derek Winter, recorded a narrative verdict.

Mr Winter found that Shaun died of natural causes contributed to by neglect.

Shaun’s mother Julie, said: “The whole family remains completely devastated regarding Shaun’s death and we all miss him daily.

"He didn’t deserve what happened.

“It has been very difficult to relive the events again during the inquest.

"It is awful to think how he suffered as a result of issues which, we will always believe, should simply never have happened.

“While nothing will ever bring Shaun back, we are committed to honouring his memory and urge all medical professionals to take steps to ensure no other family endures this kind of nightmare in the future.”

Mr Winter also made a Regulation 28 Report, also called a Prevention of Future Death Order, in relation to concerns he had regarding the medical management provided by Shaun’s General Practitioner, Dr Nandu Bhatt.

Following Shaun’s death, his mother Julie instructed specialist medical negligence lawyers at Irwin Mitchell to support them through the inquest.

Michael Scobie, the solicitor at the firm’s Newcastle office and is representing the family, said: “Julie and the rest of the family are understandably devastated and angered by the needless loss of Shaun’s life.

“This inquest has highlighted serious issues in relation to the care afforded to Shaun by his GP, and we would urge healthcare professionals to identify the lessons that need to be learned to ensure this kind of tragedy is not repeated in the future.”

Mr Scobie also read a statement from Shaun's family outside the coroner's court at Sunderland Civic Centre.

The inquest heard that in the months leading up to his trip to New York, Shaun had felt dehydrated for prolonged periods.

With a family history of diabetes, he sought medical attention to ensure he was in good-health.

On April 28, Shaun went to his GP surgery for an appointment with Dr Bhatt to discuss the symptoms he was suffering from, including an ongoing thirst and going to the toilet more often.

The following day, Shaun underwent a blood test which showed that he had a raised fasting blood glucose level.

These results were reviewed by Dr Bhatt on May 3, who planned to review them with Shaun in person.

But over two weeks later, having not been contacted by the surgery, Shaun made another appointment with Dr Bhatt himself for May 13.

Dr Bhatt prescribed metformin, a medication which is used to treat Type 2 diabetes and planned for referral to the diabetic clinic.

The inquest heard that Shaun actually had the more serious Type 1 diabetes which required urgent review and treatment with insulin.

Dr Bhatt would have known this if he had asked Shaun to do a urine test.

Tragically, instead of receiving an urgent appointment Shaun was booked in at the diabetic clinic on 23 June, almost six weeks later.

Unaware of the potential seriousness of his condition, Shaun travelled to New York City on May 26.

Mr Winter found Shaun had told his GP of his planned trip, but that Dr Bhatt, who said it had not been mentioned to him, had not "deliberately put it from his mind and did not give it the importance it required."

Several days into the trip Shaun started to become increasingly unwell with sickness and constipation.

A doctor called to his hotel said he was dehydrated and told Shaun and friend Matthew Foley he could self medicate or pay $4,500 up front for a intravenous drip or head to hospital where it could cost $10,000.

That doctor has never been traced, with Professor Ian Wall, who was commissioned by Northumbria Police as an expert witness on GP and forensic medicine, stating it would have been obvious to any medic that Shaun needed emergency treatment which in this country would have prompted a 999 call.

Anthony Haycroft, the barrister who represented Dr Bhatt, asked Prof Wall if Shaun had been admitted to hospital at that stage, 36 hours before his death and 24 hours before he suffered a cardiac arrest, treatment including insulin and fluids would have been given.

Prof Wall replied: "There's no doubt about it," leading Mr Haycroft to say this action would have saved the life of Shaun, who had hoped to go into the RAF.

Prof Wall, who said Shaun's care under the American doctor was "appalling" also expressed a number of concerns about Dr Bhatt's handling of the case and said his actions had fallen below the standard expected of him.

While Shaun had insurance, there was no cash to pay for the care and Mr Winter said he had been a "hostage to his condition" leaving him to make plans to head back to the UK on his booked flight.

Shaun had been rushed to hospital on June 2 and sadly died the following day.

Mr Winter also said he would be writing to the Foreign Office, Association of British Travel Agents (ABTA) and the Association of British Insurers (ABI) to say he believed changes must be made so people can get the care they need without having to find the money there and then.

He said: "Improvements could be put in place to ensure that an individual in Shaun's position who have insurance can get the best possible treatment and stop this type of tragedy happening again."

Mr Winter said the Care Quality Commission (CQC) and the Chief Coroner and said the General Medical Council, (GMC) could be in touch to seek documents and transcripts in relation to the inquest.

He expressed concerns about some of the “customs and practices” at Dr Bhatt’s surgery and said the inquest had heard some changes had already been made to forms and processes.

He added: "Finally, I would like to express my sadness to Shaun's friends and family and my condolences."