Sims, Desmond Arthur
Deceased
Desmond Arthur Sims
Demographics
62y, male
Date of death
2011-01-26
Finding date
2013-12-06
Cause of death
Non-small cell lung carcinoma with metastases
AI-generated summary
Desmond Sims, a 62-year-old prisoner, died from advanced non-small cell lung carcinoma with metastases. He was diagnosed with lung cancer in February 2009 at Princess Alexandra Hospital (PAH) but was lost to follow-up for 15 months due to a breakdown in the appointment booking system at PAHSU. A follow-up appointment scheduled for 19 February 2009 was never correctly entered into the tracking spreadsheet, and the PET scan results were not communicated in a manner that would prompt clinical review. When Mr Sims re-engaged with hospital services in May 2010, he repeatedly declined chemotherapy and radiation therapy. The coroner found the medical care provided was otherwise adequate and appropriate. Key lesson: robust systems for tracking specialist follow-up appointments in custodial settings are essential, particularly for serious diagnoses. Electronic integration of prison health records with hospital systems and clear communication protocols between facilities could prevent similar lapses.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Loss to follow-up for 15 months after initial cancer diagnosis
- Breakdown in appointment booking process at PAHSU
- Failure to correctly enter follow-up appointment into tracking spreadsheet
- Inadequate communication of PET scan results to treating clinician
- Patient's own disinterest in pursuing treatment enquiries
- Lack of electronic integration between prison health services and hospital systems
- Paper-based record systems in custodial setting
Coroner's recommendations
- Improve communication and information sharing between health staff at PAHSU and correctional facilities such as WCC
- Provide health staff working in prisons with access to Queensland Health intranet to replace Department of Community Safety email/IT accounts
- Transition recording and data collection processes for inmate health matters from paper-based to electronic systems
- Ensure prison health staff have access to electronic clinical resources available to similar employees in community settings
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