Inquest into the death of Melville Schrader
Deceased
Melville Ernest George Schrader
Demographics
76y, male
Date of death
2019-08-13
Finding date
2023-10-04
Cause of death
small bowel obstruction in the setting of terminal metastatic neuro-endocrine tumour
AI-generated summary
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2015 and November 2017, he submitted multiple self-referral forms reporting abdominal pain, weight loss (15kg), diarrhoea, and family history of bowel cancer. Despite nursing staff appropriately identifying need for GP review and colonoscopy, administrative failures prevented proper waitlisting. Expert oncologists confirmed earlier diagnosis (potentially December 2015) was achievable and would likely have improved his survival and quality of life. The coroner found the prison health service response 'seriously deficient' and acknowledged by the Justice Health Network. Systemic failures included errors in patient administration system data entry, poor communication between nursing staff and doctors, and inadequate follow-up mechanisms. While cure was unlikely given metastatic disease, earlier treatment would have reduced his suffering and potentially extended survival.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- delayed diagnosis of neuro-endocrine tumour
- failure to respond to multiple patient self-referral requests over 24 months
- administrative errors in patient management system
- inadequate communication between nursing and medical staff
- lack of appropriate escalation of symptoms to doctors
- failure to arrange colonoscopy despite family history of bowel cancer
- systems failure in patient self-referral process
- errors in electronic waitlist management
Coroner's recommendations
- Implementation of the Patient Health Enquiry and Self-Referral (PHES) Project across all NSW correctional centres, involving a dedicated call centre staffed by registered nurses with real-time triage capabilities
- Expansion of funding for the PHES Project to enable rollout across all NSW correctional centres
- Improved digital access to health services in correctional centres using iPads
- Continued training of agency nurses to operate the patient administration system
- Provision of special medical transport vehicles for frail and infirm inmates, as established by the Medical Escort Unit in June 2019
- Copy of findings to be provided to NSW Ministry of Health for consideration in funding applications for prison health services
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —