Coronial
NSWhospital

Inquest into the death of Michael Sanderson

Deceased

Michael James Sanderson

Demographics

53y, male

Date of death

2022-10-22

Finding date

2025-04-16

Cause of death

Metastatic pancreatic carcinoma

AI-generated summary

Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed diagnosis by six weeks; (2) adverse blood results were never explained to the inmate, preventing informed decision-making about diagnostic imaging; (3) cancer diagnosis obtained on 28 September 2022 but next-of-kin consents for health information sharing were not completed until 7 October 2022, creating 10-day communication blackout with family in remote location; (4) no clinician proactively contacted family after transfer to Prince of Wales Hospital emergency department; (5) inadequate systems for documenting and communicating approved end-of-life visit conditions to guards resulted in authorised items being refused and visits being curtailed. While earlier diagnosis may not have changed medical outcome, it would have enabled extended family contact, earlier palliative care, and exploration of early release options.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

general practicepathologyemergency medicineoncologypalliative caregastroenterology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

insulin degludec/insulin aspartinsulin aspartpregabalin

Clinical conditions

metastatic pancreatic carcinoma stage IVtype-1 diabetes mellitusdiabetic retinopathyperipheral neuropathychronic pancreatitisvitamin b12 deficiencyjaundicehepatic duct obstructionliver metastasesascites

Procedures

blood testabdominal ultrasound (declined)abdominal imaging/ct scanbiopsyendoscopic retrograde cholangiopancreatography (ercp)

Contributing factors

  • Failure to review July 2022 blood work within required 14-day timeframe (reviewed after 6 weeks on 22 August 2022)
  • Failure to communicate abnormal blood results to patient
  • Abdominal ultrasound delayed and not performed prior to inmate returning to Kirkconnell Correctional Centre after COVID-19 isolation
  • Ten-day delay in obtaining 'Consent to Liaise' form after diagnosis (28 September to 7 October 2022)
  • No clinician contact with family between 30 September and 10 October 2022
  • No single point of contact provided to family for medical information
  • Inadequate and ad hoc policies for end-of-life visits in custody
  • Breakdown in communication regarding approved visit conditions between management and guards
  • Guards not adhering to approved visit terms and conditions
  • Difficulty in obtaining information due to ambiguous next-of-kin identification in hospital records

Coroner's recommendations

  1. To JHNSW: require clinicians to consult an inmate to see if they wish to provide a 'Consent to Liaise' with next of kin concerning their health status as soon as possible after an inmate receives an advanced cancer diagnosis and/or starts receiving palliative care
  2. To JHNSW: ensure such consultation occurs prior to an inmate's transfer to Long Bay Hospital, and if not done prior to transfer, must occur at time of reception at Long Bay Hospital
  3. To JHNSW: require consultation with an inmate regarding 'Consent to Liaise' when an inmate is identified as suffering from a 'Chronic Condition' under JHNSW policy and at subsequent Chronic Condition reviews
  4. To the Commissioner of CSNSW: amend the final paragraph of Part 6.2 of the COPP 19.6 concerning prohibitions on giving of items to inmates, to refer to the potential for exceptions to be made in the case of end of life visits or palliative care visits
  5. To the Commissioner of CSNSW: ensure there is consistency between the COPP 19.6 and the current Local Operating Procedure in so far as they relate to end of life/palliative care visits

Further listening

Coronial podcast — Episode 88

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