Small bowel obstruction and acute renal failure, due to or as a consequence of metastatic colorectal carcinoma
AI-generated summary
Adrian Adams, aged 76, died in Princess Alexandra Hospital from small bowel obstruction and acute renal failure secondary to metastatic colorectal cancer. He was serving an eight-year sentence for sexual offences at the time of his death. The coroner found Mr Adams received appropriate medical care during incarceration, including regular clinical engagement with medical staff and consistent pain management aligned with his Advanced Health Directive (palliative care only). A minor issue of missed/incorrect medications was identified and corrected. The primary systemic issue was difficulty sourcing suitable nursing home placement after exceptional circumstances parole was approved in December 2020, due to facility capacity, information-sharing barriers, and financial complications. No clinical errors were identified in his terminal care management.
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Specialties
palliative careemergency medicineoncologygeneral medicineforensic medicine
Error types
medicationsystem
Drugs involved
dutasteridecoloxyl with sennaparacetamolramipriloxycodonemetforminaspirinduloxetinepregabalinoxycodonemetoclopramidemacrogol
difficulty sourcing suitable post-release accommodation after parole approval
Coroner's recommendations
Continue work on improving the process for discharging palliative care inmates to nursing homes after exceptional circumstances parole is granted, involving Queensland Health, Queensland Corrective Services, and the Parole Board
Develop clear pathways to facilitate discharge, including involvement of Ipswich Hospice as identified location for palliative end-of-life patients
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