THE death of a 17-year-old diabetic could have been prevented, an inquest heard.
Scott Slipper was found dead in his room in a homeless hostel in County Road,
Swindon, on September 7, 2004.
A review into his death, which was disclosed to the inquest, stated there was a
chance Scott's death could have been avoided.
Scott's parents Lance and Paulene Slipper said that they were failed by Swindon
Social Services.
The serious case review stated: "It can only be conjecture that the lack of
referral for assessment, the missed opportunities to assess and the quality of
assessments when made would have prevented Scott's death.
"However, as these are the tools we use to work together to address children's
needs, the panel considered that they would have made a difference."
The report made several key recommendations to stop the failings which may have
contributed to Scott's death from happening again.
Swindon coroner David Masters demanded he was kept up-to-date with the
implementation of the recommendations.
The serious case review recommended better communication between the agencies
which had been involved in the case: the police, Swindon Primary Care Trust,
Swindon and Marlborough NHS Trust and Swindon Borough Council.
In the last year of his life, Scott was admitted to hospital 28 times with
diabetic problems, and on one occasion he was taken to intensive care.
On Wednesday the inquest was told by Great Western Hospital consultant Dr Sahid
Ahmed that he thought Scott deliberately failed to take his insulin and ate
inappropriate foods in order to get admitted to hospital.
In July 2004 a member of the hospital staff recorded Scott saying he wished to
spend his birthday, which was on August 15, in hospital.
Scott spent his birthday in the paediatric ward. Mr Masters could not conclude
exactly when he was discharged due to gaps in hospital documentation, though he
thought it was probably August 16. Scott was never seen alive again.
His body was retrieved on September 7, but the pathologist who conducted the
post-mortem examination estimated that he had died more than five days
previously.
Scott's parents had lost touch with him after a violent incident at their home
in Moredon in February.
Scott's social worker Richard Tonge said he had a conversation with Mrs Slipper
on July 30, 2004, in which she said "she washed her hands of him."
Mrs Slipper denied the accusation. She said: "I would never wash my hands of my
kids.
"I wanted him back home on the understanding we got the help we needed from
social services."
Scott's parents also said they never received letters sent by Mr Tonge advising
that they take Scott back into their home.
Returning a narrative verdict, Swindon coroner David Masters said: "Scott was a
very troubled young man who had difficulties coping with his condition.
"He was treading that fine line between life and death."
Nobody knows what we went though'
FOR Lance and Paulene Slipper the verdict on Scott's death draws a line under
almost two years of pain.
We can get his death certificate and scatter his ashes now, said Mrs Slipper
after the inquest. We're going to scatter his ashes in Cornwall. We went there
every year and he loved it. He was always so happy."
However, the couple, who have two other sons, expressed disappointed at the
verdict.
Mrs Slipper added: "If he was in hospital that many times why weren't we, as the
next of kin, informed?"
The Slippers said they never received letters sent by Scott's social worker
advising them that they should take him back after he had run away.
Mr Slipper said: "Nobody knows what we went through ourselves. We were given no
assistance from any authorities.
We just needed some support because of what he was doing. Our family has been
let down by social services. If the recommendations in the report were there in
2004, there's a chance Scott would still be with us."
Boy refused to take medication
This is Wiltshire July 21, 2006
By Marcus Leroux
A 17-year-old diabetic found dead in his room had previously stopped taking
insulin in order to be admitted to hospital, an inquest heard.
Scott Slipper was found dead in a hostel for homeless people in County Road on
September 7, 2004.
The inquest finally came before Swindon coroner David Masters yesterday after
delays caused by a social services serious case review.
Scott, pictured, ran away from his parents' home in Moredon in February 2004
after a violent argument.
Mr Slipper's parents were not in direct contact with him at the time of his
death.
Scott stayed with his aunt Debbie Carroll after leaving his parents' home,
but when she was unable to house him any longer he was taken into foster care.
In July 2004 his foster parents decided that they could no longer care for him,
after he had stolen from them and suffered repeated diabetic attacks. Scott's
father Lance told the inquest of his difficulties in making sure Scott took his
insulin and medication.
He said: "In 2003 he was expelled from school and then college and then lost his
job. This was all related to him not taking his medication."
Mr Slipper added: "The more we tried to reason with him, the more he tried to
rebel against us." Mr Slipper explained how Scott would pretend to take his
insulin, and how as a result it became impossible to know whether Scott had a
safe blood sugar level.
In the months before his death Scott was admitted to hospital frequently,
sometimes more than once a week. Great Western Hospital diabetes consultant Dr
Sahid Ahmed told the inquest that he received a letter from a colleague.
This stated: "When things get tough, Scott reacts by not taking his insulin and
eating sweets and drinking Lucozade." Dr Ahmed added: "Perhaps perpetuating this
behaviour meant Scott could go to the children's ward, somewhere comforting and
safe.
"I made it clear to him that some people die from it. The reality was he knew
what he was doing."
Coroner David Masters asked Dr Ahmed if he thought Scott should have been
sectioned to prevent him from harming himself. Dr Ahmed replied: "We discussed
many times how could we break this cycle. He was doing this of his own volition.
He didn't have a suicidal air."
The inquest is scheduled to conclude today.
