Deceased
John O'Donnell
Demographics
73y, male
Coroner
Decision ofDeputy State Coroner Kennedy
Date of death
2019-09-08
Finding date
2023-09-27
Cause of death
Complications of metastatic neuroendocrine lung carcinoma
AI-generated summary
John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at Silverwater MRRC: inappropriate cell placement on the top floor despite documented age, frailty, and breathlessness requiring ground floor accommodation; and failure to administer prescribed Lanreotide injections due to incomplete information transfer between healthcare providers. The coroner found that Justice Health failed to follow up discharge documentation from Prince of Wales Hospital that would have disclosed the injection prescription. While these omissions did not alter the fatal outcome, they illustrate gaps in communication between Justice Health and Corrective Services, and in medication management for incarcerated patients with serious illness. The coroner recommended amending the Health Problem Notification Form to include explicit prompts for cell placement assessment to ensure future inmates with physical limitations receive appropriate accommodation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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