Coronial
QLDhospital

Chen, Sen Hung

Deceased

Sen Hung Chen

Demographics

65y, male

Coroner

Barnes

Date of death

2010-12-06

Finding date

2012-10-26

Cause of death

Metastatic adenocarcinoma of unknown primary origin

AI-generated summary

Sen Hung Chen, a 65-year-old prisoner with hepatitis C cirrhosis, diabetes and hypertension, died from metastatic adenocarcinoma of unknown primary origin while in custody at Princess Alexandra Hospital Secure Unit. He presented with flank pain and anorexia in June 2010; a CT scan ordered 10 August was not performed until 31 August, with results reported three days later, revealing pulmonary nodes and pleural effusion. Subsequent imaging identified hepatic lesion and metastatic disease. Care after diagnosis was of high standard including palliative management. The coroner found no deficiency in treatment, noting diagnostic delays were not unusual and would not have altered outcome. However, the three-week delay in CT imaging and three-day delay in result reporting, while not contributing to death, prompted hospital review of radiology reporting systems.

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

Specialties

palliative careradiologyemergency medicinecorrectional healthhepatologyoncology

Error types

delay

Clinical conditions

metastatic adenocarcinomahepatocellular carcinomahepatitis C cirrhosistype II diabetes mellitushypertensionpleural effusionpulmonary nodes

Procedures

CT scan

Contributing factors

  • Hepatitis C cirrhosis
  • Type II diabetes mellitus
  • Hypertension
  • Advanced metastatic cancer

Coroner's recommendations

  1. Princess Alexandra Hospital to continue implementation of electronic radiology reporting system to improve access to results by treating clinicians
Full text

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