Finding into death of Thomas James Brigham

Contributing factors

• delayed diagnosis of lung cancer
• focus on musculoskeletal pain obscured investigation of systemic disease
• inadequate baseline investigations for persistent unexplained symptoms
• absent or ineffective communication between prison health service and external hospital
• lack of written discharge summary or documentation from ED
• failure to obtain chest X-ray despite respiratory symptoms
• patient may have been poor historian and did not fully disclose symptoms
• weight loss and poor appetite not sufficiently investigated as red flags

Coroner's recommendations

1. Department of Justice initiate and maintain appropriate performance audits of health service providers to ensure diagnostic services available to general population are available to prison population
2. Department of Justice ensure health service providers implement cancer screening programs to prevent unduly delayed cancer detection and treatment
3. Department of Justice ensure health service providers have procedures for written communication (transfer forms, discharge summaries) between primary and tertiary care providers with acknowledgement of receipt protocols, with prioritized introduction of electronic health record systems
4. Processes to ensure follow-up appointments are booked at time of review to prevent oversight
5. All prisoners returning from ED should be reviewed by nursing staff within 24 hours with written communication (discharge summary/letter) from hospital to prison
6. Availability of medical file summary at external hospital appointments (not full file but relevant written summary)
7. Clinical judgement-based consideration of telephone contact between ED doctor and prison medical staff before finalising treatment plans
8. Results of pathology, radiology, or investigative procedures disclosed to patient by general practitioner or qualified health professional
9. Implementation of Justice Health notifiable incident directive for persistent pain lasting more than 14 days
10. All pain of unknown origin without improvement over two weeks should undergo further diagnostic testing and be managed with structured care program
11. Referral to tertiary care if symptoms persist or worsen over 4-week period