Harrison, Steven Leslie

Contributing factors

• Unrecognised and unmanaged severe coronary atherosclerosis
• Missed radiological findings of abdominal aortic calcification on CT scans (2013, 2015) and X-ray (2016)
• Inadequate cardiovascular risk assessment despite diabetes diagnosis since 2001
• Failure to perform lipid profile testing on re-incarceration in 2016
• Absence of baseline ECG despite multiple cardiovascular risk factors
• Non-compliance by patient with medical appointments and recommendations
• Diabetes poorly controlled with low blood sugar episodes
• Heavy smoking history and intravenous drug use
• Incidental radiological findings not actioned as clinical triggers

Coroner's recommendations

1. Implementation of standardised cardiovascular risk assessment protocols for prisoners with diabetes and other cardiovascular risk factors
2. Baseline ECG should be performed on intake and during incarceration for high-risk individuals
3. Establishment of systematic review processes to ensure incidental radiological findings (such as atherosclerosis) are actioned as clinical triggers
4. Implementation of a Nurse Practitioner/Nurse Navigator role for chronic disease management in correctional facilities to flag abnormal investigation results and query need for further investigations or medication modifications
5. Transition to electronic medical record system across all correctional facilities to ensure information sharing of health issues and continuity of care
6. Routine lipid profile testing and cardiovascular work-up in line with RACGP guidelines for absolute cardiovascular risk assessment
7. Enhanced follow-up processes to ensure prisoners who miss appointments are rebooked promptly
8. Patient education about cardiovascular disease risk factors and lifestyle modifications including smoking cessation