Coroner's Finding: MILLER Franklin Delano

Contributing factors

• failure to pursue specialist referral for indeterminate liver lesion identified in December 2006
• adoption of passive 'wait and see' approach rather than prompt investigation
• inadequate explanation to patient of cancer risk and consequences of non-investigation
• lack of documentation of patient's stated refusal to travel to Adelaide
• failure to adequately counsel patient on worst-case scenarios
• poor continuity of care between privately practising GPs and prison health service
• absence of senior medical oversight of serious/life-threatening illnesses in prisoners

Coroner's recommendations

1. Medical Director of South Australian Prison Health Service should assign a senior medical officer responsibility for oversight of medical treatment and investigation of prisoners suspected of serious or life-threatening illness, especially where treatment is provided by non-Service practitioners
2. Medical practitioners treating prisoners should carefully explain to reluctant patients the possible consequences of failure to undergo important medical treatment or investigation, including identification of worst-case scenarios
3. Medical practitioners should make detailed notations in clinical records of decisions by prisoners to refuse recommended treatment or investigation, including stated reasons
4. Medical Director and CEO of Department for Correctional Services should recognise that prisoner refusal to travel to Adelaide does not prevent compulsory transfer and escort
5. Medical Director and CEO should ensure that conditions enjoyed by prisoners in country facilities are not jeopardised by necessity of travel to Adelaide for medical treatment or investigation