Inquest into the death of Ivan MILAT
Deceased
Ivan Milat
Demographics
74y, male
Date of death
2019-10-27
Finding date
2021-02-16
Cause of death
metastatic gastro-oesophageal adenocarcinoma
AI-generated summary
Ivan Milat, aged 74, died of metastatic gastro-oesophageal adenocarcinoma whilst in lawful custody at Long Bay Correctional Centre. He presented with gastrointestinal symptoms from October 2018, was initially treated for Helicobacter pylori, but declined gastroscopy investigations initially. After progressive weight loss and swallowing difficulties, he underwent diagnostic workup at Prince of Wales Hospital in May 2019, revealing metastatic cancer. Palliative oesophageal stenting and radiation therapy were provided. The coronial investigation found that appropriate medical investigations were conducted, he was appropriately transferred to the Medical Subacute Unit when his condition deteriorated, and adequate palliative care was provided. The coroner found no evidence that medical care contributed to his death. A procedural issue was identified: media notification occurred before next-of-kin notification, which CSNSW subsequently remedied.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Patient's initial refusal of gastroscopy investigation
- Delay in diagnosis due to patient declining investigations against medical advice
Coroner's recommendations
- CSNSW amended Custodial Operations Policy and Procedures to ensure that when media inquiries occur about deaths in custody, confirmation of the death is only provided after obtaining confirmation from relevant authorities that the inmate's next of kin or emergency contact person has been notified of the death
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