Coronial
SAother

Coroner's Finding: BALLARD Kenneth Frederick

Deceased

Kenneth Frederick Ballard

Demographics

75y, male

Date of death

2016-05-05

Finding date

2021-01-15

Cause of death

cerebral metastatic malignancy (lung cancer with brain metastases)

AI-generated summary

Kenneth Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused travel to Adelaide for specialist haematology review, citing severe distress from prison bus transport and haematemesis. Dr Kavanagh documented his capacity to refuse treatment. His condition deteriorated significantly by early 2016. A CT scan in April 2016 revealed advanced lung cancer with brain metastases, presenting with seizures. He died weeks later. The coroner found the lung cancer was likely a separate entity from his original leukaemia and may have been undiagnosed earlier, but Mr Ballard's own refusal to travel for specialist care and his choice to remain in the prison setting limited diagnostic opportunities. Earlier diagnosis was uncertain to improve outcome.

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Specialties

general practicehaematologyoncologyneurologyemergency medicinecorrectional health

Error types

diagnosticdelay

Clinical conditions

chronic lymphocytic lymphomalung cancercerebral metastasesseizureshaematemesisanaemiagastric fundal bleedingprior cerebrovascular accident

Procedures

lymph node biopsyCT scan head and neckCT scan full bodyendoscopic adrenaline injection for gastric bleedingultrasound

Contributing factors

  • patient refusal of specialist review and transport to Adelaide
  • patient preference to remain at Mount Gambier Prison despite declining health
  • limited haematology and oncology services at Mount Gambier Prison
  • adverse effects of road transport causing patient distress
  • masking of lung cancer symptoms by pre-existing chronic lymphocytic leukaemia
  • delayed diagnosis of lung cancer until advanced stage
Full text

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