Coroner's Finding: SFYRIS Michael
Deceased
Michael Sfyris
Demographics
50y, male
Date of death
2016-04-05
Finding date
2019-05-14
Cause of death
carcinomatosis due to metastatic, poorly differentiated renal cell carcinoma unclassified (sarcomatoid-type)
AI-generated summary
Michael Sfyris, a 50-year-old prisoner, died of metastatic renal cell carcinoma in April 2016. A CT scan performed in September 2015 revealed an adrenal lesion but the radiology report was misfiled and not reviewed for 2.5 months. When reviewed in January 2016, the findings were non-specific and did not suggest malignancy. A subsequent scan revealed stage 4 incurable cancer with metastases. The coroner found the delay in reviewing the September report and subsequent delays in medical review due to escort unavailability were failures in prison health management. However, the coroner concluded the delay likely had little bearing on the outcome, as the cancer was rapidly progressive, the initial findings were non-specific, and the patient refused active treatment until parole. The case highlights systemic failures in prisoner healthcare record management and coordination.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- delay in reviewing radiology report from September 2015 (2.5 months)
- misfiling of CT scan results in prison health system
- delayed medical review due to unavailable escorts
- non-specific initial radiology findings
- patient refusal of active treatment until parole
- rapidly progressive metastatic cancer
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