Lingwood, Craig Steven

Contributing factors

• initial mischaracterisation of lesion as benign by prison doctor in 2006
• failure to perform biopsy on suspicious lesion despite clinical indicators
• loss of urgent referral from hospital dermatologist to Lesion Clinic (February 2008)
• lack of formal system in prison for tracking and following up referrals to external providers
• hospital failure to follow up or verify that referred patient received appointment
• delay of approximately 2 years between initial presentation and definitive excision
• absence of structured follow-up plan post-excision despite Stage IIa disease
• no regular surveillance between July 2009 and July 2010
• late detection of metastatic recurrence (July 2010)
• inadequate policies and procedures for prisoner referral management

Coroner's recommendations

1. Implement formal policies and procedures for monitoring and tracking medical referrals of prisoners to external service providers (subsequently implemented by CQHHS in September 2013)
2. Ensure full skin examinations are conducted routinely upon prison reception for all prisoners (subsequently implemented in March 2011)
3. Establish systems to formalise the Medical Request Form process and ensure appropriate urgency is assigned (formalised in July 2011, revised 2012)
4. Implement photography protocols for mole/skin condition monitoring (introduced July 2010)
5. Establish structured follow-up and review plans when prisoners are discharged from hospital after treatment for serious conditions such as melanoma
6. Enable electronic access to Queensland Health IT clinical systems (HBCIS) at correctional facilities to allow verification of referral status and appointments
7. Develop collaborative processes between prison health services and hospital outpatient departments to ensure urgent referrals are actioned and tracked