Coronial
NSWprison

Inquest into the death of Keith HOWLETT

Deceased

Keith Howlett

Demographics

49y, male

Coroner

Decision ofDeputy State Coroner Grahame

Date of death

2013-05-24

Finding date

2017-03-31

Cause of death

complications of non-small cell carcinoma of the lung

AI-generated summary

Keith Howlett, 49 years old, died from complications of non-small cell carcinoma of the lung while in custody at Junee Correctional Centre after 5 weeks of incarceration. He had complex medical needs including HIV, peripheral vascular disease, and depression. The coroner found the transfer of care from community to custody was below best practice. Dr Baguley did not establish meaningful therapeutic relationships, failed to obtain specialist information about cancer prognosis, did not complete a comprehensive health assessment plan, and did not recognise palliative care needs despite Howlett receiving such care in the community. Symptoms including severe vomiting, diarrhoea, pain, and weight loss were inadequately managed. No psychiatric assessment occurred despite known mental health issues. The death was natural and likely not preventable, but the coroner found his final weeks unnecessarily uncomfortable and distressing, with missed opportunities for appropriate symptom management and care planning.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practiceoncologypalliative carepsychiatryinfectious diseasescorrectional health

Error types

diagnosticsystemcommunicationdelay

Clinical conditions

non-small cell carcinoma of the lungHIVperipheral vascular diseasedepressionanxietychronic PTSDnausea and vomitingdiarrhoeachronic paininsomniagastro-oesophageal reflux diseasehypercholesterolaemia

Contributing factors

  • failure to obtain specialist information from community treating doctors
  • inadequate assessment of palliative care needs
  • failure to recognise and manage complex medical symptoms
  • inadequate nausea and pain management
  • lack of therapeutic relationship between patient and medical staff
  • incomplete comprehensive health assessment plan
  • failure to refer for psychiatric assessment despite known mental health conditions
  • no specialist cancer review
  • failure to coordinate care with community providers
  • lack of palliative care training for custodial medical staff

Coroner's recommendations

  1. Consideration be given to developing and implementing a palliative care training package for all nursing and medical staff within Justice Health, and including all other providers of medical services contracted to Corrective Services. In particular training should address the early recognition of palliative care intervention for all inmates diagnosed with serious and life threatening illnesses and/or illnesses that may require opiate/analgesic relief.
  2. Immediate consideration be given to creating a designated position and central location to resource and support medical staff across NSW in relation to palliative care options for all inmates.
  3. Immediate consideration be given to mandating that all inmates identified with cancer be given the option of being reviewed by the Cancer Care Nurse (who shall be provided access to the necessary medical information and support systems) within an appropriate and fixed time frame.
  4. A brochure is developed for inmates in relation to the palliative care and cancer support services available within the NSW custodial system, (including the part of that system which is privately operated).
  5. Annual auditing of GEO Health Services (or any similar contract providers) include a face-to-face interview component with a percentage of randomly selected inmates currently receiving health services.
  6. Annual auditing of GEO Health Services (or any similar providers) should include mandatory checking compliance with tools such as the Chronic Disease Screen.
Full text
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