Coroner's Finding: RJR
Demographics
65y, male
Date of death
2022-11-10
Finding date
2025-08-28
Cause of death
metastatic rectal cancer with extensive lung metastases
AI-generated summary
A 65-year-old man died from metastatic rectal cancer with extensive lung metastases while serving a prison sentence. He had presented with rectal bleeding symptoms since 2011 and returned a positive faecal occult blood test in March 2015 recommending colonoscopy. However, he subsequently declined multiple colonoscopy offers in 2018 and 2020 despite medical recommendation. A colonoscopy performed in October 2018 was incomplete due to poor bowel preparation, and he refused repeat investigation. When he finally consented to colonoscopy in June 2021, a large necrotic rectal mass was discovered with liver and lung metastases already present. The coroner found the standard of medical care provided was optimal and equivalent to or better than community standard. The delay in diagnosis was attributable primarily to the deceased's repeated refusal of recommended investigations rather than deficiencies in medical care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- deceased's repeated refusal to undergo recommended colonoscopy investigations
- positive faecal occult blood test not followed by colonoscopy in 2015
- incomplete colonoscopy in 2018 due to poor bowel preparation
- deceased's decline of repeat colonoscopy after incomplete 2018 procedure
- two-month wait for colonoscopy after consent in June 2021
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