Simon Hockenhull

I am Elizabeth WHEELER, Assistant Coroner for the coroner area of Cheshire

On 06 December 2024 I commenced an investigation into the death of Simon HOCKENHULL aged 56. The investigation concluded at the end of the inquest on 10 June 2025. The conclusion of the inquest was that: Natural causes

Mr Hockenhull died at his home address on 5 December 2024. He had been diagnosed with diabetes in 2017. Since diagnosis, he had struggled to control this. His diabetes, and the poor management of the same, led to gastro-intestinal issues. The underlying diabetes and the associated gastro-intestinal issues made him more prone to contracting infections and more vulnerable when he did contract them. In 2024, his diabetic control significantly worsened. He was admitted to the ICU multiple times over that year as a result of diabetic ketoacidosis. From 2 December 2024, Mr Hockenhull’s brother and community healthcare professionals became concerned about Mr Hockenhull’s health. On 5 December, he was found collapsed but breathing at his home. His brother called emergency services, but by the time paramedics arrived, Mr Hockenhull had died. Mr Hockenhull died as a result of contracting lobar pneumonia, contributed to by his underlying diabetes and diabetic gastro enteropathy which materially reduced his resilience

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.  In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) In the course of this inquest, I have heard that some diabetic medications and devices have a life span of 14 days.  When two are prescribed, they therefore amount to a 28 day supply. I have heard that this can cause problems as there are some pharmacists who interpret a 28 day supply as a “month”, and that it can therefore be challenging to obtain a further prescription within the same calendar month.  For patients who already have a complex relationship with their medication and monitoring regime, the challenges this causes can mean that they then do not take their medication as consistently as they need to. For patients with a diagnosis of diabetes, this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis. At the heart of the issue seems to be that a “month” is being inconsistently defined. Sometimes it means 28 days, sometimes it is a calendar month. The RCGP RPS “Repeat Prescription Toolkit” (October 2024) does not seem to address this issue, so it may be that prescribers and dispensers are unaware of this issue.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.