Fifteen-year-old Christian Williams had Type 1 diabetes and was in Arizona DCS custody at a Catalyst group home in Mesa. Emails warned that missed insulin “will result in his death.” A DCS-contracted worker asked for a nurse. An emergency team met. Nothing changed. On July 7, 2024, staff framed a medical crisis as misbehavior and delayed 911. Christian died three days later of diabetic ketoacidosis. Licensing took no action. This investigation follows each warning, each decision, and the policies that should have protected him.