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22
Aug 2023
Harrogate musician died from poorly-managed diabetes, inquest finds
A talented Harrogate musician diagnosed with diabetes at 18 died eight years later from the disease, an inquest heard today.
Aaron Joseph Bertenshaw was 26 when he went into a diabetic coma and died at his home in Dene Park in December 2021.
At the inquest in Northallerton, coroner Catherine Cundy heard evidence that he had struggled to come to terms with his diagnosis and the condition had not been well managed.
Mr Bertenshaw, a popular musician who also worked as a barber, was admitted to the emergency department of Harrogate District Hospital 40 times over a period of five years.
Of those, 36 admissions were because of diabetic ketoacidosis (DKA), which occurs when the blood glucose level is dangerously high.
Following his high frequency of admission to hospital, a multi-disciplinary team meeting was called in April 2021, involving the GP practice as well as the hospital's diabetes team.
As well as his poor diabetes control, health professionals were concerned that he failed to keep appointments or respond to attempts to contact him.
The meeting considered whether Mr Bertenshaw had the mental capacity to make decisions in his own interests and it was agreed this would be assessed whenever contact was made with him in future.
However, the psychiatry team at Harrogate District Hospital never felt that Mr Bertenshaw had an underlying mental health problem that would have impacted on his ability to make decisions.
Mental health
The consultant psychiatrist, Dr Akram, told the court Mr Bertenshaw had had a number of referrals to mental health services over several years, the latest in October 2021.
He said patients in acute episodes of DKA can lack judgement and behave strangely, but this does not mean they have a mental health disorder.
Nor, he said, can someone be detained under the mental health act to force them to accept treatment, which Mr Bertenshaw's parents had suggested could have been done for him.
The community mental health team felt that Mr Bertenshaw was struggling to accept his diagnosis, but was not deliberately misusing his insulin.
Dr Akram added:
The inquest also heard that the diabetes team at the hospital had discussed different options with Mr Bertenshaw to help him manage his condition.
He had requested going onto an insulin pump, which diabetes consultant Dr Sutapa Ray told the inquest had been "on the table" for him.
She said Mr Bertenshaw was told he first needed to have his sugar levels under control, which he had not been able to do.
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Mr Bertenshaw's mother, Sammy Oates, told the court he had lost a significant amount of weight and vomited after every meal, causing her to suspect he had an eating disorder.
However, Dr Ray said this was a common symptom in cases of poorly controlled diabetes, and Mr Bertenshaw had not engaged well with the diabetes team to help him manage the condition.
She said:
The court heard Mr Bertenshaw had avoided emergency admission to the hospital for most of 2021.
When he was admitted in early October, he said he had been drinking and taking cocaine following the death of a friend. Having initially refused tests and treatment, he did later agree to accept help.
He was again referred to the mental health team but, despite repeated attempts to contact him, he failed to respond.
Aaron Bertenshaw was a well-known musician who gigged around Harrogate
On Thursday, December 2, 2021, Mr Bertenshaw's mother went to his house, having not been able to contact him or seen him active on WhatsApp since Monday, November 29.
She found him on his living room floor, and paramedics attended to confirm his death.
Police officers who were also present reported signs of a "chaotic" lifestyle, including an unhealthy diet, and use of alcohol and drugs.
The post-mortem and toxicology reports found that while there was some cocaine in his system, it was not in large enough quantities to have put him at risk of death. However, the court heard use of cocaine is thought to be linked to a higher risk of DKA.
Concluding that Mr Bertenshaw had died of natural causes relating to his diabetes, Ms Cundy said she had not seen any evidence that more could have been done to intervene by the organisations caring for him.
She said she accepted that sectioning him to force him to take medication was not appropriate, adding:
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