Inquest into the death of Mervyn Douglas Morgan
Deceased
Mervyn Douglas Morgan
Demographics
59y, male
Date of death
2020-01-05
Finding date
2022-11-24
Cause of death
complications of viral liver cirrhosis with hepatocellular carcinoma
AI-generated summary
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite May 2017 abnormal findings until July 2018); inadequate communication of serious ultrasound results to the patient, leading to informed refusal of further imaging; gaps in clinical handover between facilities and staff transitions; lack of formal documentation and follow-up of advance care planning decisions in December 2019 when Mr Morgan changed his mind about treatment and resuscitation. While the cancer diagnosis ultimately proved terminal, earlier appropriate monitoring and clear patient communication might have enabled earlier treatment decisions. Transfer documentation lacked advance care planning details, creating confusion at Prince of Wales Hospital about his wishes, though this did not affect his final palliative care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- delayed initiation of surveillance ultrasound despite abnormal findings in May 2017
- failure to refer for ultrasound between September 2017 and June 2018
- inadequate communication of serious July 2018 ultrasound results showing suspicious lesions
- lack of proper follow-up when patient declined imaging appointments
- insufficient documentation of refusal discussions without clear recording of risks explained
- poor clinical handover between correctional facilities during transfers
- inadequate advance care planning documentation in December 2019
- failure to complete updated resuscitation plans when patient changed mind about treatment
- missing advance care directive and resuscitation plan information in emergency transfer documentation to Prince of Wales Hospital
- staffing gaps: limited administrative support, frequent staff transitions, lack of GP follow-up
Coroner's recommendations
- Justice Health to amend standard paperwork utilised when transferring patients to incorporate a specific check for indicating whether a patient has an advance care directive or resuscitation plan in place
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