Coroner's Finding: DODSON Edward Leonard

Contributing factors

• delayed diagnosis and investigation of elevated PSA levels
• failed urology appointment in March 2011 due to no doctor availability
• 18-month gap in urological follow-up between April 2011 and October 2012
• initial reluctance or refusal to travel to Adelaide for investigations
• failure to refer to visiting urologist at Port Lincoln until October 2012
• inadequate investigation of liver metastases to identify primary source
• inadequate documentation of patient refusals and advice given
• progressive liver disease despite prostate cancer remission suggesting non-prostatic primary

Coroner's recommendations

1. The Medical Director of the South Australian Prison Health Service should assign senior medical officer(s) responsibility for maintaining oversight of medical treatment and investigation of prisoners suspected of serious or life-threatening illness, especially when treatment is conducted by non-Service practitioners.
2. Medical practitioners treating prisoners should carefully explain to reluctant prisoners the possible consequences of refusing important medical treatment or investigation, including worst-case scenarios.
3. Medical practitioners should make detailed notations in prisoner clinical records documenting: the prisoner's decision to refuse recommended treatment/investigation, the stated reasons for refusal, and any advice given that the treatment/investigation should be undertaken.
4. The Medical Director and Chief Executive Officer of the Department for Correctional Services should recognise that a prisoner's refusal to travel to Adelaide for medical treatment does not prevent the Department from requiring the prisoner to travel to Adelaide and be accommodated in an Adelaide correctional facility.
5. The Medical Director and Chief Executive Officer should ensure that conditions enjoyed by a prisoner in a country correctional facility are not jeopardised by the need to travel to Adelaide for medical treatment or investigation.