Andrew Hadwin

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Independent investigation into
the death of Mr Andrew Hadwin,
a prisoner at HMP Durham,
on 2 February 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Andrew Hadwin died of diabetic ketoacidosis on 2 February 2023 at HMP Durham. He
was 39 years old. I offer my condolences to his family and friends.
On 1 February, Mr Hadwin had not taken his insulin. He said this was because he was not
prescribed the correct dose. Healthcare staff were aware and action was being taken. Mr
Hadwin was also being monitored as at risk of suicide and self-harm and had talked about
killing himself. Mr Hadwin understood the potentially fatal consequences of not taking his
insulin, however, there is insufficient evidence for us to conclude that he intended to die.
The clinical reviewer concluded that the healthcare Mr Hadwin received at Durham until 1
February was equivalent to what he could have expected to receive in the community, his
care from that date was not.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman February 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On 17 January 2023, Mr Andrew Hadwin was remanded to HMP Durham charged
with multiple sexual and child neglect offences.
2. Mr Hadwin had pre-existing medical conditions, including angina, type 1 diabetes
and high cholesterol. He previously had two heart attacks, and in 2020, he had an
upper gastrointestinal bleed. He used a walking stick to move around and a
wheelchair for longer distances.
3. During his initial health screen, a nurse noted Mr Hadwin’s medical conditions. She
took his blood sugar level, which was high, and his blood pressure and pulse were
raised. The nurse tested his urine and the results indicated that no ketones (a type
of chemical the liver produces when it breaks down fats) were present. There is no
evidence that the nurse rechecked his blood pressure and pulse or that she had
escalated the raised readings to a GP.
4. Mr Hadwin was subject to suicide and self-harm monitoring (known as ACCT). He
said that he had frequent thoughts of suicide and had a plan for killing himself, but
would not discuss this further with staff.
5. Mr Hadwin believed his insulin dose was incorrect and healthcare staff looked into it
for him. A GP confirmed that he should be prescribed a higher dose but healthcare
staff advised that the dose would be slowly increased. Mr Hadwin did not collect his
insulin as prescribed on 1 February. A nurse spoke to him, and he confirmed he
understood the potential fatal consequences of this.
6. On 1 February, Mr Hadwin complained of chest pains. Prison staff radioed a
medical emergency code and control room staff called an ambulance immediately.
A nurse responded and took a note of Mr Hadwin’s observations, which were all
within a normal range. She completed a NEWS2 assessment and concluded that
he scored three. She did not refer him to a GP for further review and instructed the
control room staff to cancel the emergency ambulance and asked healthcare staff
to continue to monitor him.
7. At 8.42am on 2 February, a nurse saw Mr Hadwin after he complained of stomach
pain. She attempted to take his blood sugar level, but it was too high to obtain an
accurate reading. She administered his insulin and offered him pain relief, which he
refused. She asked another nurse to arrange the GP review. There was no GP on
duty at the prison that morning, so he would not have been able to see a GP until
later that afternoon. The nursing staff did not consider contacting an out of hours
GP or sending Mr Hadwin to hospital for further review.
8. At 11.10am, a prison officer opened Mr Hadwin’s cell door. His cell mate told the
officer that Mr Hadwin had been in the toilet area of the cell for approximately 30
minutes. The officer went into the toilet area and found Mr Hadwin unresponsive.
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9. The officer radioed a medical emergency code and staff in the prison control room
telephoned for an emergency ambulance immediately. Other prison officers
responded and started cardiopulmonary resuscitation (CPR). Paramedics arrived
shortly afterwards and took over Mr Hadwin’s care. At 12.01pm, they confirmed that
Mr Hadwin had died.
Findings
10. Mr Hadwin had spoken of his constant thoughts of suicide and that he had a plan.
On 1 February, he did not take his insulin and said he understood the potentially
fatal consequences of this. However, it is not clear that his decision not to take his
insulin properly in the days before his death amounted to a clear intent to die.
11. The clinical reviewer concluded the healthcare Mr Hadwin received at Durham until
31 January 2023 was equivalent to that which he could have expected to receive in
the community. The care he received from 1 February 2023, was not.
12. When Mr Hadwin arrived at Durham, healthcare staff failed to complete a full set of
clinical observations. The nurse had identified that his blood pressure and pulse
were elevated, but she failed to investigate this further or refer Mr Hadwin to a GP
for an urgent review.
13. When Mr Hadwin complained of chest pain on 1 February 2023, a nurse based her
assessment of his symptoms on his medical history and did not fully assess him
based on the symptoms he presented at the time. Also, when Mr Hadwin presented
with concerning symptoms the next day, healthcare staff failed to escalate this to an
out of hours GP or send Mr Hadwin to hospital despite there being no GP available
until the afternoon.
Recommendations
• The Head of Healthcare should ensure that a full set of clinical observations
are taken during reception screening in accordance with NICE guidance and
any anomalies escalated to a senior clinician.
• The Head of Healthcare should ensure that all staff receive appropriate
training in differential diagnosis pathways, and all pathways are considered
when attending an emergency response.
• The Head of Healthcare should ensure that:
• staff are able to decide if an urgent appointment demands an immediate
response; and
• staff know how to escalate if a further on-site clinical assessment is not
available at the desired time.
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The Investigation Process
14. HMPPS informed us of Mr Hadwin’s death on 2 February 2023.
15. The investigator issued notices to staff and prisoners at HMP Durham informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
16. The investigator obtained copies of relevant extracts from Mr Hadwin’s prison and
medical records.
17. NHS England commissioned a clinical reviewer to review Mr Hadwin’s clinical care
at the prison.
18. We informed the Coroner for County Durham and Darlington of the investigation.
The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
19. Mr Hadwin did not name anyone as his next of kin.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS/Spectrum Community Health did not find any factual inaccuracies.
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Background Information
HMP Durham
21. HMP Durham is a local prison, serving the courts of Tyneside, Durham and
Cumbria. It holds approximately 1,000 male prisoners. Spectrum Community Health
CIC provides primary healthcare services. Tees, Esk and Wear Valleys Foundation
NHS Trust provides mental health services.
HM Inspectorate of Prisons
22. The most recent inspection of HMP Durham was in November 2021. Inspectors
reported that serious staff shortages had affected all aspects of healthcare provision
and caused delays. Although the Head of Healthcare had a clear vision, oversight
and strategic management had been affected by the lack of a deputy and the need
for her to be involved in clinical delivery.
23. Inspectors also found that new prisoners often arrived late in the day and a
significant number did not receive an initial health screen before going to their cells.
There was insufficient GP capacity to see patients and manage the range of
associated tasks. Prisoners with long-term health conditions did not always receive
personalised care, or timely reviews. This had recently been addressed by the
appointment of a lead nurse for patients with complex care needs.
Independent Monitoring Board
24. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 October 2021, the IMB
reported that although prisoners reported good relationships with healthcare staff,
they were frustrated about healthcare provision (which had been affected by the
COVID-19 pandemic).
25. The IMB had similar concerns about initial health screens and found that only a
small percentage of prisoners received their second-stage health screen within
seven days.
Previous deaths at HMP Durham
26. Mr Hadwin was the tenth prisoner at Durham to die since February 2021. Of the
previous deaths, six were from natural causes and three were self-inflicted. There
has been one further death since Mr Hadwin’s death, which was self-inflicted.
27. In our investigation into the death of a prisoner at Durham in February 2021, we
made a recommendation that urgent requests to see a GP at the prison should be
actioned quickly. The healthcare provider accepted our recommendation and told
us there was a standard operating procedure in place to support escalation and
defensible decision making in respect of GP referrals.
28. In our investigation into the death of a prisoner at Durham in September 2022, we
recommended that healthcare staff carry out a full set of observations during initial
health screens. The healthcare provider accepted our recommendation and said
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that the requirements for initial health screens were displayed in the reception area.
The provider also reinforced the requirements in an email sent to all healthcare staff
reminding them of the NICE guidance in respect of this matter. It is disappointing
that we are raising these issues again in this report.
Assessment, Care in Custody and Teamwork (ACCT)
27. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
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Key Events
28. On 17 January 2023, Mr Andrew Hadwin was remanded to HMP Durham charged
with multiple sexual and child neglect offences.
29. At his initial health screen, a nurse noted that Mr Hadwin had arrived in prison with
several pre-existing conditions which included two heart attacks in 2012
(necessitating a surgical procedure to insert a stent to improve his blood flow),
angina, for which he required GTN spray (Glyceryl trinitrate used to alleviate chest
pain, which he admitted he did not use correctly) and high cholesterol. Mr Hadwin
told her that he had also suffered an upper gastrointestinal bleed in 2020. The
nurse noted that he had mobility issues and that he used a walking stick and a
wheelchair to move around.
30. The nurse made a note of Mr Hadwin’s blood pressure, which she recorded as
raised at 122/102mgHg (a normal blood pressure is considered to be
120/80mmHg). His pulse was also raised at 115bpm (a normal pulse rate is
considered to be 60-100bpm). She did not re-check his blood pressure and raised
pulse or escalate the matter to a senior clinician.
31. Mr Hadwin told the nurse that he had been diagnosed with type 1 diabetes at the
age of 18 and that he was dependent on insulin. She took his blood sugar level
which she recorded as 24 mmol/L (a normal blood sugar level is between 4 and 6
mmol/L). Mr Hadwin said that his usual reading was around 9 mmol/L. She then
tested his urine for ketones, which would indicate that his diabetes had deteriorated.
The results showed that there were no ketones present.
32. Mr Hadwin also told the nurse that he had harmed himself by cutting his wrists in
2012, after he had been accused of committing sexual offences, and that he had
been admitted to a mental health unit in 2015. When she asked him about his
current mood, he said that he had no thoughts of suicide or self-harm. She
considered Mr Hadwin would benefit from a more intensive level of support and
started suicide and self-harm prevention procedures, known as ACCT. She
identified his concerns, namely that he was unable to contact his partner for
support, who was also his co-defendant, as she had been sent to HMP Low
Newton. He also told her that he felt unsafe in prison because the details of his
offences were being reported in the media. She ensured Mr Hadwin had the
relevant contact details of his partner and that he was moved to the prison’s
Vulnerable Prisoner wing. She also recorded in Mr Hadwin’s ACCT document that
prison staff should have hourly interactions with him as part of the ACCT monitoring
process. Mr Hadwin wrote to his partner on 23 January.
33. On 18 January, a nurse saw Mr Hadwin. He told her that he had had a daily
prescription for a 30ml novorapid insulin pen (a rapid-acting insulin used to treat
diabetes mellitus) in the community. Because healthcare staff were unable to
confirm this until they had received his community health records, they contacted an
out of hours GP service for advice. The GP prescribed Mr Hadwin a 15ml dose of
Novorapid and asked the nurse to ensure that Mr Hadwin’s blood sugar levels were
monitored regularly, and that his urine be regularly tested for any evidence of
ketones.
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34. In the early hours of 19 January, a nurse checked Mr Hadwin’s blood sugar level,
which was 19.4 mmol/L. She also tested his urine, and the results showed evidence
of ketones. She spoke to another nurse, who advised her to send Mr Hadwin to
hospital by emergency ambulance, which she did.
35. A pharmacist received Mr Hadwin’s community health records which confirmed that
from June 2022, Mr Hadwin had been prescribed 30ml novorapid. She passed the
information on to staff at University Hospital North Durham.
36. At hospital, Mr Hadwin was diagnosed with diabetic ketoacidosis (DKA, which
occurs when the body has insufficient insulin causing the liver to break down fat for
fuel; high levels of ketones can build up to dangerous levels in your body and can
be fatal) and poor compliance with his insulin. He was admitted to hospital as an
inpatient and hospital staff stabilised his condition. On 23 January, Mr Hadwin was
discharged from hospital and returned to HMP Durham.
37. That day, a pharmacist noted that Mr Hadwin had been discharged from hospital
without an up-to-date list of prescribed medications. She continued with his existing
prescription of 15ml Novorapid daily.
38. Later that day, a nurse from the prison’s Mental Health Inreach Team (MHIRT) saw
Mr Hadwin. Mr Hadwin told her about his mental health history and that he had no
current thoughts of self-harm. However, during an ACCT case review, Mr Hadwin
told the meeting that he felt more suicidal than he did before he went to hospital. He
said that he had no current plans to attempt suicide and said that ‘he had stuff he
needed to sort out’ and needed to contact his solicitor about his appeal against his
sentence. Mr Hadwin continued to be managed under ACCT procedures until his
death.
39. On 25 January, a GP at the prison saw Mr Hadwin after he had reported having
fallen on two occasions. He noted that Mr Hadwin’s breath smelt of pear drops (a
sign of possible DKA). He sent Mr Hadwin to hospital by emergency ambulance.
Hospital staff confirmed that Mr Hadwin had developed DKA. He was admitted to
hospital as an inpatient and his condition stabilised. He was discharged back to
Durham on 27 January. He was still prescribed 15ml Novorapid.
40. During an ACCT case review, that day, Mr Hadwin hold the meeting that he had too
much on his mind to think about attempting suicide, but said that he did have plans
and ideas on how he would do it but would not disclose anything further. He
confirmed again that he had no immediate plans to attempt suicide.
41. On 30 January, a nurse saw Mr Hadwin to assess if he needed a higher level of
input from healthcare staff. She noted that he had difficulty sleeping, had type 1
diabetes resulting in chronic diabetic neuropathy (high blood sugar levels cause
damage to the small blood vessels supplying the nerves in the body resulting in
damage), had a carer prior to being sent to prison, had been admitted to hospital
due to DKA and was being managed under the ACCT process. Following her
review, she referred him to the Complex Care manager for further assessment.
42. Later that day, a nurse saw Mr Hadwin. He told her that he was concerned because
he still had not been prescribed the correct dose of insulin. He also complained of
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bleeding from both ears and of a headache. She noted that he had no active
bleeding at the time of her review. She checked his blood sugar levels, which she
recorded as 25.1 mmol/L. Mr Hadwin told her that this was a reasonable level for
him. She tested his urine and recorded a ketone level of 2.1. She asked another
nurse to recheck his blood sugar level and his urine.
43. In the early hours of 31 January, a nurse saw Mr Hadwin. He told her that he still
had a headache, but that he felt fine. She noted there was no sign of bleeding from
his ears, and he had not vomited. He told her he had not eaten anything due to not
getting the correct does of insulin. She checked his blood sugar level and recorded
it as 20.9 mmol/L. She also tested his urine for evidence of ketones and noted the
level was 1.4, lower than his last test. She referred Mr Hadwin to a GP for further
review.
44. Later that day, another GP at the prison saw Mr Hadwin. The GP noted that there
was some discrepancy as to what level of insulin Mr Hadwin should be prescribed.
He decided to review Mr Hadwin’s prescription of 15ml Novorapid once his fasting
blood glucose level had been established and also after his blood sugar level had
been tested prior to every meal for the next three days.
45. Following an ACCT case review on 31 January staff recorded that Mr Hadwin had
not self-harmed or attempted suicide since being in prison, but reported constant
thoughts of suicide. An officer asked Mr Hadwin what it was that was stopping him
and what he was using as a protective factor. Mr Hadwin said that he had nothing to
do it (attempt suicide) with. He said he still had plans but again would not elaborate
on what they were.
46. At 2.51pm on 1 February, Mr Hadwin complained of chest pains. An officer radioed
a code blue (indicating a prisoner is unconscious or is having breathing difficulties)
and control room staff called an emergency ambulance immediately. A nurse
responded. She took a note of Mr Hadwin’s observations, which were all within a
normal range. She completed a NEWS2 assessment (National Early Warning Score
a system for identifying acutely ill patients) and concluded that he scored three,
which meant that a clinician needed to see him. She tested his blood sugar level,
which was 23.5, but there is no evidence that she tested for ketones. She
considered the pain he was experiencing was in fact stomach pain that was
radiating to his chest. She instructed that the emergency ambulance be cancelled,
and that healthcare staff review him again later that day.
47. At 5.17pm, a nurse actioned her colleague’s request and saw Mr Hadwin. She
noted that there was no record of him attending the medication hatch for insulin that
day and considered that the pain he had experienced was due to him not complying
with his insulin regime. She asked him what he thought the possible consequences
of his non-compliance with prescribed medications might be. He said that he
understood that he may die. She took a note of his observations, which were within
a normal range and referred him to a GP for further review. There is no evidence
that she tested his blood sugar levels and ketones as part of her observations.
48. Later that day, a Custodial Manager (CM), a security manager at Durham,
telephoned the healthcare department. He spoke to the nurse and asked her to
ensure that Mr Hadwin was only sent to hospital for further review if it was
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absolutely necessary. She told him that Mr Hadwin had been reviewed and that
there were no immediate concerns.
Events of 2 February
49. On 2 February, Mr Hadwin complained of stomach pains again and a raised
breathing rate. At 8.42am, a nurse took his observations and recorded his
temperature as 35.6 degrees Celsius, his pulse raised at 140bpm, respiratory rate
as 18 breaths per minute and his oxygen saturation level as 96%. She attempted to
record his blood sugar level, but it was too high to obtain a reliable reading. She
recorded his NEWS2 score as four. She considered that a GP needed to see him
urgently. She administered his insulin and offered him pain relief, which he refused.
She told him she would arrange for an urgent GP review and advised him to ask
healthcare staff for further assistance should his condition worsen.
50. Because she was dispensing medications at the time of her review, she asked
another nurse to make the urgent referral to the GP on her behalf. The other nurse
asked a member of the healthcare administration team to request an urgent GP
appointment, which they did. However, there was no GP on duty at the prison until
the afternoon. None of the healthcare staff involved contacted an out of hours GP or
considered sending Mr Hadwin to hospital for urgent review. They did not appear to
know how to escalate their concerns to senior healthcare staff and as a result,
accepted an afternoon GP appointment.
51. At 11.10am, an officer opened Mr Hadwin’s cell so that he and his cell mate could
go for lunch. The officer could not see Mr Hadwin in the cell. Mr Hadwin’s cell mate
told the officer that Mr Hadwin had been in the toilet area of the cell for
approximately 30 minutes. The officer called Mr Hadwin’s name, but Mr Hadwin did
not respond. He went into the toilet area and saw Mr Hadwin slumped to one side
on the toilet. He checked for a pulse but found none. He radioed a code blue and
control room staff telephoned for an emergency ambulance immediately.
52. Two officers responded to the code blue. The officers moved Mr Hadwin onto the
floor of his cell and began CPR. A nurse responded, taking with her an emergency
grab bag and defibrillator. Two more nurses also responded. Assisted by officers,
they moved Mr Hadwin out of his cell and on to the landing. They then took over
CPR. A nurse attached the defibrillator to Mr Hadwin’s chest, and it advised no
shock and to continue CPR.
53. Paramedics and helicopter emergency responders (HEMS) arrived shortly
afterwards and took over Mr Hadwin’s care. They administered eight shots of
adrenalin and a saline drip. However, Mr Hadwin did not respond.
54. At 12.01pm, a HEMS doctor confirmed that Mr Hadwin had died.
Contact with Mr Hadwin’s family
55. When he arrived at Durham, Mr Hadwin told staff that he had no next of kin. Due to
the nature of Mr Hadwin’s offending behaviour, he did not have any contact with his
family.
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56. Prison staff contacted HMP Low Newton and a senior manager there notified Mr
Hadwin’s partner of his death.
Support for prisoners and staff
57. After Mr Hadwin’s death, the Duty Governor carried out a post-incident debrief with
the staff involved in the emergency response. The staff were also offered welfare
checks following the incident.
58. The prison posted notices informing other prisoners of Mr Hadwin’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Hadwin’s death.
Post-mortem report
59. The pathologist gave Mr Hadwin’s cause of death as diabetic ketoacidosis.
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Findings
60. Throughout his time at Durham, Mr Hadwin was subject to suicide and self-harm
monitoring procedures. He told staff that he had thoughts of suicide and a plan of
how he would kill himself, which he would not divulge. However, he also said he
had too much on his mind to sort out to kill himself.
61. Mr Hadwin was concerned that he was not being prescribed the correct dose of
insulin. Healthcare staff were aware and taking action to rectify this. On 1 February,
Mr Hadwin did not take his insulin. A nurse discussed this with him and he
confirmed that he understood the potentially fatal consequences of this. We
consider there is insufficient evidence to conclude that Mr Hadwin’s poor
compliance with his insulin prescription in the days before his death amounted to an
intent to die.
Clinical care
62. The clinical reviewer concluded that the initial healthcare Mr Hadwin received at
Durham was equivalent to what he could have expected to receive in the
community, but the care he received from 1 February was not. She identified some
aspects of his care where improvements could have been made.
Initial health screen
63. NICE (National Institute for Care and Health Excellence) Guidance NG57 (Physical
health of people in prison), states that a full set of clinical observations should be
completed when a prisoner arrives in custody. The guidance also states that if a
prisoner’s blood pressure or pulse are recorded as raised during the health screen,
the test should be repeated, or the results escalated to a senior clinician.
64. When a nurse carried out Mr Hadwin’s initial health screen on 17 January 2023, she
recorded his blood pressure and pulse as raised. However, neither was rechecked
or escalated to a senior clinician as it should have been. There is also no evidence
that she completed a full set of clinical observations, as she should have done. We
recommend:
The Head of Healthcare should ensure that a full set of clinical observations
are taken during reception screening, in accordance with NICE guidance and
any anomalies escalated to a senior clinician.
Diagnosis of Mr Hadwin’s condition
65. When Mr Hadwin complained of chest pain on 1 February 2023, a nurse reviewed
him. However, she did not consider that there may have been another reason for
the symptoms he presented with, not related to his previous heart and
gastrointestinal concerns. In particular, she did not apparently consider his unstable
diabetes and history of DKA when assessing him. We recommend:
The Head of Healthcare should ensure that all staff receive appropriate
training in differential diagnosis pathways, and all pathways are considered
when attending an emergency response.
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66. The nurse reviewed Mr Hadwin again at 8.42am on 2 February, after he again
complained of stomach pains. She asked a colleague to make an urgent referral for
a GP appointment on her behalf. Her colleague asked a member of the admin team
to action the request. When it became clear that the soonest a GP could examine
Mr Hadwin was later that afternoon, no one considered contacting the out of hours
GP service for advice, or calling an ambulance. An urgent GP appointment should
demand an immediate clinical response. We recommend:
The Head of Healthcare should ensure that:
• staff are able to decide if an urgent appointment demands an immediate
response; and
• staff know how to escalate if a further on-site clinical assessment is not
available at the desired time.
67. The clinical reviewer made other recommendations about defensible decision
making and record keeping, which we do not repeat in this report, but which the
Head of Head of Healthcare will need to address.
Good Practice
68. Two nurse should be praised for the way they conducted their part in the ACCT
process. Both of them, correctly, determined that what an individual says they
intend is only one factor, and not a very reliable one, in assessing the likelihood of
self-harm. They both considered all of the surrounding risks and Mr Hadwin was
cared for under ACCT for the entirety of his time at Durham. This good practice
should be widely shared with other staff.
Inquest
69. The inquest, held from 28 to 31 October 2024, concluded that Mr Hadwin died from
natural causes related to type one diabetes. Self-neglect was listed as a
contributory factor due to his refusal to take insulin to treat his diabetes, and his
actions were in an attempt to take his own life. There were failing in the testing of
his ketones on 1 and 2 February which also contributed to his death.
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