Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including chronic heart failure, renal impairment, diabetes, and COPD. While receiving medical care both in custody and at St Vincent's Hospital, she missed a scheduled renal clinic review in August 2013, despite plans for follow-up. The coroner noted this omission but concluded it did not contribute to her death. The case highlights the importance of robust systems to ensure continuity of specialist care for chronically ill patients in custodial settings, and the need for contracted health service providers to develop processes that do not rely solely on external appointment coordination.
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Specialties
cardiologynephrologyrespiratory medicineoncologygeneral medicineforensic medicine
System failure in coordinating external specialist appointments for chronically ill inmates
Coroner's recommendations
Contracted health service providers such as GEO Care develop systems and processes to avoid reliance on external providers for specialist appointment coordination
Monitor the provision of external appointments to ensure patient omissions do not occur in the future
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