QLDother

Sims, Desmond Arthur

Deceased

Desmond Arthur Sims

Demographics

62y, male

Coroner

Ryan

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. Report an inaccuracy.

Specialties

respiratory medicineoncologycardiologypalliative careforensic medicine

Error types

systemcommunicationdelay

Clinical conditions

non-small cell lung carcinomametastatic cancerischaemic heart diseaseemphysemabronchiectasiscoronary atherosclerosis

Procedures

bronchoscopyPET scanCT scanchest x-raypost-mortem CT scan

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

Full text

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