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."