Diabetic complications induced by Abilify (aripiprazole) - no glucose monitoring -

IN MEMORIAM

Anthony Santin y Ogueta 

(25 juillet 1992 — 5 mai 2024)

Death following diabetic complications induced by Abilify (aripiprazole) and no glucose monitoring during 9 years and, moreover, having been the subject of psychological abuse

Here follows the sad story of my Son :

COMPLAINT  TO THE NATIONAL MEDICAL BOARD

Date

By Registered Mail

XXXXXXXXXXXXX

XXXXXXXXXXXXX

XXXXXXXXXXXXX

SUBJECT: Complaint against Psychiatrist XXXXXXXXXXX

Dear Sir,

I hereby file a complaint with the XXXXXXXXXX against psychiatrist XXXXXXXXXX for breach of duty of care, which resulted in the death of my son, Anthony SANTIN Y OGUETA, 31 years old, and also I file a complaint for psychological mistreatments (see at the end of this document).

A- BACKGROUND:

My son, at the age of 18, suffered a severe panic attack—this occurred during the period of the divorce of his parents. He was initially hospitalized in XXXXXX for four months to manage his anxiety. He was prescribed the medication Haldol. Once his condition had stabilized,he was sent to a secondary school in a standard academic program without any special arrangements due to his still very fragile condition.

There had been no supportive medication at that time.

He was living with his mother (filipina) and his mother did not allocate him any resource, not even a little pocket money and he could not even afford a can of soda, he was 19 years old.

His mother was not poor she bought 2 new houses and some lands in his country and planned to start a construction business in that same country.

One day he kicked the door of the sleeping room because he needed money to buy something (not drugs/alcohol) but his mother refused as always to give him an allowance for whatever reason despite the fact she was working in a hospital.

She called the police and he was taken to the psychiatric emergency of XXXXXXXXX.

He was not in a psychotic crisis (delirious) but simply angry because he never got a penny from his mother and was not still able to work. 

This general hospital sent him to the psychiatric institution of xxxxxx. During the emergency , he declared that he wanted to return to school and that he did not want to go to the asylum; the psychiatrists called in the security guards to restrain him; it was a terrible moment for him and his father who was present.

In the end he gave in and was sent to the psychiatric institution of XXXXXXXX, that decision will be fatal for my Son.

There he spent two weeks in an observation cell strictly like in a prison with a cell door made of iron bars, locked in with only a tiny bed. No communications with the outside were allowed.

It was at that time – November 2015 – that psychiatrist XXXXXXXXXX became  his regular psychiatrist and diagnosed him with schizophrenia (this diagnosis will turn out to be wrong). 

That psychiatrist had just finished his studies, my Son was his first patient and that will also be fatal for him.

He was the only psychiatrist and doctor he saw in his entire short life (he refused to consult a family doctor).

In the meantime my Son had been granted the right to social benefits.

His mother told me that if he comes to live with her, she will take all the social benefits for herself.

To prevent this, we had to call in a property administrator (lawyer) to manage my Son's allowances.

This will ultimately prove to be a bad idea because, to put it bluntly, we had to choose between two unscrupulous thieves.

Upon his release from that hospital my Son came to live with me because his mother no longer wanted him and announced during a meeting with the psychiatrist, my son and myself, and before any consultation with him and me, her intention to place him permanently in the asylum, which surprised everyone.

He was supposed to take 30 mg of Abilify, the maximum dose, every day from the start without titrating the drug, already a first serious mistake.

Throughout his life he had only experienced one episode of paranoid stress when his mother abandoned the family home.

This behavior is not delusional or dangerous enough to warrant administering the maximum dose of antipsychotics from the beginning, which simply condemns him to social instability because resuming education, for example, was impossible due to the medication's side effects at the maximum dose.

The first time I met my son at the hospital he was wandering barefoot through the corridors, delirious talking about nightmares of blood; he was  worse than when he had arrived, in fact when he arrived there he was ok he said " I dont want to go to that hospital I have to go to school tomorrow", his speech was not delirious at all.

He was incredibly worse in that asylum than before he entered it.

Is this normal ?

No medical history was done by the psychiatrist during the first and subsequent consultations and he simply asked one question : "Did you take your drug ?", period.

In fact,my Son was the one who initiated the conversation trying to build a relation but the psychiatrist was not at ease and to make a long story short, he cut the session before the 30 minutes,it was more like 20.

I was present at each of his consultations with the psychiatrist.

B- PERSONALITY:

He went through a normal secondary education.

He was well-integrated, had many friends, and enjoyed a trouble-free teenage life – no drugs and never any alcohol – and tested negative at the hospital for the hashish.

He was passionate about computers and above all graphic cards and mobiles, he found always customers on Facebook to buy and resell his stuff and never ask for money to buy new devices . He spoke french and english. He also really loved manga,especially One Piece (He died the day of one Piece's birthday), and video games. 

He tried on his own to find work and resume his studies but he said it was impossible to concentrate because of the antipsychotic.

Here are the facts on which the complaint is based:

C- GENERAL MEDICAL CONTEXT AND INFORMATION HELD BY THE PSYCHIATRIST

-This information was primarily provided by myself during the consultations-:

1. I told the psychiatrist on more than one occasion about my anxiety and helplessness regarding the fact that my son was drinking 4 to 5 liters of lemonade per day - 3 to 4 large bottles - and he was so addicted to sugar that he would go to the local supermarket to buy bags full of sugary drinks.He would do this when I was at work, or very late at nigh he would have a sugar craving and go to a convenience store to buy several cans of sugary drinks.

2. This frenzied pattern of sugar consumption began approximately less than a year  after he started the intake of the Abilify 30 mg.

3. I informed the psychiatrist that my son had systematically refused to see a general practitioner since the beginning, i.e., 2015; he was not registered as a patient with any doctor. I tried three times to register him at the nearby Medical Center XXXXXXXX, but each time he refused to come to the appointment.

4. My son was followed by this psychiatrist from 2015 until his death on May 5, 2024. He saw him once a month.

5. My son did not consult any other doctor, specialist, or psychologist during all those years—he refused to see any other doctor except the psychiatrist—and the psychiatrist was aware of this fact.

6. The initial prescription was Abilify 30 mg, the highest dose according to the psychiatrist himself, and remained so throughout the 10  years of treatment.Strictly no change and no monitoring of the metabolism.

7. Abilify is an antipsychotic which, like all antipsychotics, has a negative impact on blood glucose levels, and blood glucose monitoring should be ensured according to current medical recommendations. 

Here nothing was done during 10 years.

The only request for a blood glucose test was simply forgotten; no reminder, no results, no enforcement action. Just to mention here that the psychiatrist was quiet angry at my request to impose a glucose test to my Son, he said "it's not me who has to do that !" 

8. I told him that I myself was diabetic and that his mother was also diabetic.

9. My son was diagnosed by the psychiatrist as schizophrenic. He was aware of the resistance of schizophrenic patients to any treatment; it is a well-known characteristic of schizophrenia. There is no compliance.

10. He gave him a form to do his glucose test, specifying that normally it wasn't him who should do this—but he only had him as a 

doctor—and my son didn't go for the glucose test. However, at the next consultation, the doctor made no mention of it. The test he had asked him to take was simply ignored and never mentioned again in subsequent consultations. 

11. There was never any coordination with other doctors – endocrinologist or otherwise – it should be noted that my son refused all contact with doctors except this psychiatrist, and I informed him of this fact, but nothing came of it.

Shouldn't the psychiatrist ensure that the patient receives comprehensive care for their various conditions?

12. The psychiatrist never explained to my son – or to me – the consequences of untreated diabetes, particularly its impact on his immune system. The refusal of care should have been well documented; in my son's case, there was no warning about it, no discussion.

13. To date, there are no blood glucose reports concerning my son during his treatment from 2015 to 2024. The only blood glucose test was performed by the paramedic on April 24, 2024, in his room. My son was in a semi-comatose state and had a blood glucose level of 4.60 grams.

The most dramatic consequence was that his immune system had collapsed due to years of untreated diabetes, and he was infected with the streptococcus germ, which led to his death.

D- IMPORTANT QUESTIONS:

1- Who should have periodically tested my son's diabetes based on the facts listed above, given that he was not being followed by any other doctor because he refused to consult any other doctor, and the psychiatrist knew this—I had informed him of this crucial fact—?

2- Why was there a breach of the duty of care?

3- Why was there a lack of information provided?

4- Why was there a lack of follow-up regarding his refusal to consult and have a family doctor?

5- Why didn't the psychiatrist take the management of diabetes seriously, given that it is a pernicious chronic disease with serious consequences—in this case, fatal, as in the case of my son's death—if left untreated in a highly diabetogenic context (family history, consumption of several liters of sugary drinks per day, taking the highest dose of antipsychotics, etc.)? And why did my son refuse to consult any other healthcare professional except the psychiatrist?

If a psychiatrist is aware that a patient refuses to manage their diabetes and that this management is crucial for their survival, they must take appropriate measures such as involuntary hospitalization, as the law allows it in certain cases of behavior that seriously endangers the patient's life, and this was indeed the case here, by refusing to treat their diabetes for several years. 

E- IN SUMMARY:

My son exhibited the following behavioral patterns:

1. Refusal to have a family doctor during the 10 years of treatment,

2. Refusal to have his blood sugar or other metabolic tests done,

3. Drank 4 to 5 liters of sugary drinks per day,

4. Refusal to report any ailments such as headaches, stomach aches, fatigue, general malaise, etc.,

5. Refusal to handle administrative matters such as renewing his ID card,

6. Complete refusal to accept any training offers,

7. Refusal to visit his family and cousins,

8. Refusal to continue his leisure activities such as going out, movies, etc.

The psychiatrist was aware of all these risky behaviors of social withdrawal and of the risks he was taking, particularly regarding his diabetes.

However, all these behavioral signs indicated that his treatment – Abilify 30 mg –was not working. He should have been hospitalized again for a reassessment of his treatment and for management of his diabetes, for he was putting himself in grave danger by systematically refusing all appropriate care.

9 Yet this psychiatrist did absolutely nothing and changed nothing about the treatment for nine years; a treatment that clearly wasn't working.I asked the psychiatrist to prescribe Metformin, but he refused without taking any further action.

Several months later, I was fed up with his inaction and insisted he give my Son a glucose test. He was angry, saying it wasn't his responsibility to do the test, but he didn't have a family doctor, a fact that had been brought to his attention several times.

The following month, I really didn't want to see this man anymore, but my son wanted to continue seeing him. I thought he would ask if he had taken the test, but no, nothing. He remained motionless and silent, staring at us like a judge without saying a word. Then I realized he had forgotten the glucose test again—the only glucose test in 9 years-. This was the umpteenth mistake/oversight on his part.

 I was absolutely furious, so much so that my throat was completely blocked, and I couldn't speak. My son didn't say anything either. 

10 I thought that the psychiatrist would mention it in the other appointments, but in the end, nothing; he hadn't written anything in his file.

11 that psychiatrist forbidden me to send him emails for whatever reason.

12 Anthony died sometime the following month.

And when the psychiatrist found out, he told me he didn't know the diabetes was so serious. 

There's no worse insult than that.

There was a breach of the duty of care, and my son ultimately paid for it with fatal diabetes and its complications.

In nine years of medical follow-up, this psychiatrist never bothered to check my son's blood sugar, despite all the information he was given about his confirmed diabetic behavior.

That would have saved him.

F- EMERGENCY CALL TO 112.

As a result, on April 24, 2024, I had to call an ambulance because was Son was unable to wake up. His glucose level was 4.60 g/L, the maximum being 1.20 g/L. He was in a semi-comatose state.

At the emergency unit of the XXXXXX hospital, I learned that his immune system had completely collapsed due to untreated diabetes for years, allowing a microbe—streptococcus—to infect him via the spinal fluid and then spread to other organs, particularly the heart and brain, causing irreparable damage -generalized septicemia-.

My son underwent surgery in early May—on the 4th—by Professor XXXXXXXXX to repair the ventricle destroyed by the microbe, it was an operation that lasted 4 or 5 hours which had gone well, but after some time there was a massive hemorrhage against which the surgeons could do nothing, even though they operated again for 9 hours - 3 hours x 3 - consecutively.

I had been warned that if the operation to stop the hemorrhage had been successful, my son would have remained severely disabled for life. The neurological damage caused by the streptococcus germ was very significant, and he had severe cerebral edema with total and certain paralysis of his entire right side. He had already lost the ability to speak and would have suffered from other disabilities that would have developed progressively.

The surgeons told me they could no longer transfuse him and that they had to stop the blood circulation machine. Furthermore, my son was still unconscious. 

There was nothing more that could be done, and my son died a few minutes after the machine was turned off.

G- DEATH:

My 31-year-old son died on May 5, 2024, at the Sart-Tilman University Hospital in appalling conditions.

It was a preventable death; a simple blood glucose test would have sufficed, and my Son would still be with me and his beloved sister...

Signed

XXXXXXXXXXXXXXXXX

Attachments:

1. Copy of my son's identity card

2. Copy of death certificate

3. Scientific documentation

---------------

Complaint against the psychological mistreatments.

8/17/2025

To:

Medical Expert XXXXXXXXX

Subject:

Information on the inappropriate professional conduct of psychiatrist XXXXXX

– consequences for a young patient -

Dear Sir,

In connection with the complaint, I wish to bring to your attention the following elements concerning the behavior observed in psychiatrist XXXXXXX, which,according to my observations, directly resulted in the impossibility of establishing a therapeutic relationship with the patient 

Anthony SANTIN Y OGUETA, 

a young patient being treated for stress disorders associated with antipsychotics (Abilify) induced diabetes.

1 The patient unfortunately died following the refusal of treatment for his diabetes known by the psychiatrist but left untreated despite having no family doctor, fact also known by him and last but not least, having put him on treatment with ABILIFY 30 mg, the highest dose for 9 years and without diabetic monitoring,this drug produces diabetes in one out of five patients, this fact was indicated by the psychiatrist himself.

1. Background

Patient: [Anthony, 31 years old, deceased]

Known conditions: schizophrenia + type 2 diabetes (it will appear later that that was not the right diagnostic).

Initial goal of psychiatric care: to establish a therapeutic alliance in order to:

1. support adherence to medical care and overall psychological well-being,

2. Observed behaviors (by the father, who has been present at all sessions since the beginning).

The following incidents occurred from the very first sessions with psychiatrist XXXXXXX:

A) Remarks about physical appearance:

 Criticism of the patient's hair from the beginning of the first session and in a systematic manner at each session, even though the patient showered before going to the psychiatrist's office and washed his hair, which exacerbated his feelings of humiliation.

B) Criticism of clothing style:

Explicit statement that, if he were an employer, he would not hire him because of his appearance. The patient wore clean clothes—jeans and a sweatshirt.

C) Demeaning comparisons:

Comparison with other patients, emphasizing that the patient was "more unstructured" than them. 

That remark made him feel depressed, sorrowful andhopeless. 

There were only criticisms, but no solutions were proposed which is a remarquably poor backup from a psychiatrist.

D) Hurtful mockery regarding a study plan:

Cruelly laughter and a mocking attitude when the patient expressed a desire to pursue a bachelor's degree in business (HEC). This reaction deeply hurt the patient.

E) At the beginning of the session:

The psychiatrist stood straight without smiling in a very rigid manner and stared at us without saying a word . He remained like that for several minutes; it was intimidating and instilled a feeling of fear, like being in front of a judge. This was systematic.

Overall tone: A series of remarks perceived as demeaning and humiliating,without any apparent therapeutic purpose, and recurring.

2. Observed Consequences

A) Immediate breakdown of the therapeutic relationship:

The patient expressed a profound feeling of devaluation and humiliation, which led to a complete rejection of the relationship with this psychiatrist.

B) Loss of confidence in the psychiatric care system:

The patient refused any further follow-up with other professionals.

C) Indirect impact on physical health:

This overall rejection of the care system contributed to the patient's refusal to treat his diabetes, with the aforementioned fatal outcome.

3. Conclusions

The behaviors described above appear incompatible with ethics and good psychiatric practice, particularly in the care of vulnerable patients requiring a strong therapeutic alliance.

I am forwarding this information to you for consideration in your medico-legal analysis of the case.

I remain at your disposal to provide any additional information or clarifications that may be useful to you.

Please accept, Mr. XXXXXXXXX, the expression of my highest consideration.

NB: The psychiatrist always allowed sessions with the father present, which prevented the patient—who has since passed away—from expressing himself freely, as well as the father. This constitutes professional misconduct, as itrepresents a breach of the therapeutic framework and a violation of professional confidentiality.

Furthermore, it should be noted that psychiatrist XXXXXXXX quickly prohibited email exchanges, as this was the initial method of informing him of changes indates, etc.,

This goes directly against medical law regarding communication between patients and doctors.