Coroner's Finding: Curran, Michael Anthony

Contributing factors

• failure to implement six-monthly liver ultrasound screening despite specialist recommendation
• lack of coordination between prison health services and hospital specialists
• multiple prison transfers disrupting continuity of care
• absence of electronic medical record system with clinical alerts
• failure to formalize cirrhosis diagnosis despite biopsy findings of severe fibrosis
• late diagnosis of hepatocellular carcinoma when already advanced and metastatic
• two failed courses of hepatitis C treatment with no documented follow-up monitoring strategy

Coroner's recommendations

1. That the Medical Director of the South Australian Prison Health Service assign to a senior medical officer or officers within the Service the responsibility of maintaining oversight of the medical treatment and investigation of those prisoners within institutions operated by the Department for Correctional Services who are suspected of suffering from a serious or life threatening illness, especially in circumstances where the medical treatment and investigation of such prisoners is being conducted by medical practitioners who are not employees of the Service