AIMS: Published rates of deaths attributed to diabetes mellitus among those aged under 50 have risen substantially in several former Soviet republics since the late 1980s. The reasons for this increase, and the situation facing patients with diabetes in these countries are poorly understood. The aim of this study was to describe the circumstances leading up to the death of individuals dying under the age of 50 years with mention of diabetes on their death certificate. METHODS: Interviews with surviving relatives or neighbours, combining elements of verbal autopsy and confidential enquiry. For those who had lived in the city of Lviv a random sample was taken. For those in rural areas a purposive sample was used to ensure coverage of more and less remote areas. RESULTS: Key informants were identified and agreed to be interviewed for 64 individuals out of a possible 79 with insulin-treated diabetes identified from their death certificates. The main immediate causes of death were renal failure (69%), ischaemic heart disease (9%), ketoacidosis (6%) and hypoglycaemia (3%). Over a third of men, but no women, were reported to have been heavy drinkers. Informants described many difficulties in obtaining regular supplies of insulin and related supplies since 1990. Although insulin is officially available free of charge, most had retained supplies for use in an emergency. More than half had, at some time, purchased supplies. The large number of deaths from renal failure reflects the effective absence of renal replacement therapy for patients with diabetes. CONCLUSIONS: Individuals with diabetes in Ukraine face profound challenges involving access to necessary care. Their needs require significantly more attention from policy makers.