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.
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Specialties
gastroenterologyhepatologyinfectious diseasesgeneral practicepalliative careemergency medicinecorrectional health
hepatitis C viral infectioncirrhosis of the liverhepatocellular carcinomametastatic hepatocellular carcinomahepatic failureascitescholestasisdyspneaabdominal pain
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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