Diabetic teenager died after being "let down" by agencies
A diabetic teenager, who died while in the care of Herefordshire Council, was "let down" by agencies working with him, a serious case review has found.
The 17-year-old, known only as HH, died from diabetic ketoacidosis at supported housing in Ross on Wye in May because he had not taken medication.
The report found NHS and council teams failed to ensure his "complex health and social needs were met".
The authority said it had since improved services for young people.
The independent report was commissioned by the Herefordshire Safeguarding Children Board (HSCB).
It showed HH, who was originally from Poland, was diagnosed with type-1 diabetes in January 2012.
It said that he had experienced neglect at home and was left homeless in March after his mother asked him to leave.
Herefordshire Council arranged for him to live in supported housing.
'Threaten his life'
The review said not enough was done at that time to make sure all agencies had enough information about his condition.
It said: "It is clear that, while a number of the professionals involved with HH were aware that his diabetes could threaten his life, many were not.
"If he had received medical help in the days immediately before he died, had he managed his condition better, and had he received more support, help, encouragement... he may still be alive."
The report also found, because HH was 17, there was confusion over whether he should be treated as a child or an adult.
Herefordshire Council said it had introduced new procedures to help its workers deal with vulnerable young people better in the wake of HH's death.
Staff training had also been carried out and a review of some support services had begun, it said.
Chair of the HSCB, David McCallum, said: "This is a very sad case brought about because not all the agencies involved understood the severity of this young man's medical condition.
"Every agency and practitioner involved in this case would have wanted a different outcome for him and we are all sorry for his death."