Deceased
Noel Robert Rogerson
Demographics
50y, male
Coroner
Coroner Heather Spooner
Date of death
2009-03-28
Finding date
2011-08-17
Cause of death
Chronic liver disease (alcohol, hepatitis C) with hepatocellular carcinoma and cirrhosis
AI-generated summary
Noel Robert Rogerson, a 50-year-old prisoner with chronic liver disease (alcohol-related cirrhosis and hepatitis C), died from decompensated liver disease with hepatocellular carcinoma on 28 March 2009 at St Vincent's Hospital. The inquest identified system-level shortcomings in prison health management rather than direct clinical failures. Key issues included: inadequate medical alert rating (M2 instead of M1), delayed implementation of a chronic health care plan despite chronic liver disease diagnosis in 1993, lack of a formal palliative care plan, and poor information-sharing between Justice Health and contracted health service providers including St Vincent's Hospital. The HMIT review found his final month clinical care was appropriate. However, earlier structured monitoring and clearer documentation of his terminal prognosis might have enabled better custodial management and consideration of compassionate release. The coroner found these shortcomings unlikely to have prevented death but made recommendations for systemic improvements in medical alert ratings, palliative care planning, and inter-agency communication protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…
Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despit…
11y · Male·complications of bowel obstruction in the setting of chronic constipation
RDZ was an 11-year-old Aboriginal boy who died from complications of bowel obstruction secondary to chronic constipation with a fecalith. He had been under paediatric care for years with multiple admissions for bowel was…
70y · Male·haemoperitoneum secondary to ruptured spleen following colonoscopy
Alan Edward Stewart, aged 70, died from haemoperitoneum due to splenic rupture following routine colonoscopy at Royal Melbourne Hospital on 15 August 2018. The splenic injury was caused by mechanical trauma from the colo…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.