Finding into death of Mladen Jovanoski

Contributing factors

• Failure to facilitate timely medical treatment for suspected metastatic thyroid cancer
• Three cancellations of urgent tertiary hospital appointments without clinical input
• Lack of communication between correctional and health services regarding medical priority
• Administrative and operational staff making cancellation decisions without clinical consultation
• Significant delay in medical treatment (over 4 months)
• Prisoner's increasing anxiety and frustration about unresolved medical condition
• Prisoner's anxiety about criminal proceedings and likely sentence
• Incarceration and prison environment stress
• Telephone conversation with legal practitioner immediately before death acting as trigger

Coroner's recommendations

1. Corrections Victoria consider further updating its procedures to require that any decision to cancel a medical transfer must, where relevant, first involve referral to the Health Services Manager at the prisoner's home prison or a clinician who is best placed to advise on the priority to be given to the case
2. Corrections Victoria implement a policy to require all persons involved in a decision to cancel a medical transfer to record: the circumstances; the reasons; and the persons involved, and implement a system for doing so
3. Corrections Victoria and Justice Health develop a tool to guide persons in an operational setting so that an anticipated cancellation of a transfer may be properly escalated in advance of the potential loss of the scheduled medical appointment
4. Corrections Victoria investigate the feasibility of adding a warning flag (not containing any medical information itself) in the Prisoner Information Management System (PIMS) or other system to highlight the need for priority of a medical transfer where clinically indicated
5. Corrections Victoria investigate the feasibility of adding an alternate intermediate location in the PIMS where the circumstances relating to the individual prisoner allow
6. Corrections Victoria re-establish its quarterly governance forum or comparable process capable of monitoring its response to issues identified, and recommendations made, by JARO, Justice Health or similar entities