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Endocrinologist Flags Alarm Issues and Memory Concerns in Daylesford Crash Inquest

The inquiry is testing whether diabetes care or device alerts failed to avert the beer‑garden deaths.

Overview

  • Treating specialist Matthew Cohen told the court the driver likely needed fast‑acting glucose and a meal during the hypoglycaemic episode and said dried fruit and nuts would have been insufficient.
  • Dr Cohen said he was concerned by William Swale’s memory gaps and noted he had previously recommended a refresher course in 2016, after which written materials were emailed.
  • The doctor testified there was a known lag of about 10–15 minutes in the Libre app’s readings at the time and said awareness of alarm issues grew after an FDA notice in February 2025.
  • Phone analysis showed 10 low‑glucose alarms between about 5:18pm and 6:07pm, yet Swale said he did not hear them and suggested his car’s Bluetooth may have muted alerts.
  • Records and CCTV presented to the court showed a 2.9 mmol/L reading at 5:17pm, a brief deli visit without food, a subsequent U‑turn, and the 6:07pm crash; the compelled witness apologised as the inquest continues.