Finding into death of Douglas Earnest Stott

Contributing factors

• Refusal of treatment in March 2020 and November 2020
• Unwillingness to transfer via Port Phillip Prison to access tertiary care
• Absence of clinical escalation protocols for prisoners refusing treatment
• Delayed diagnosis and monitoring due to treatment refusals
• Aggressive nature of lymphoma

Coroner's recommendations

1. Implementation of clinical escalation protocols when prisoners refuse treatment due to reluctance to transfer via Port Phillip Prison, allowing direct transfer to required hospital service and bypassing Port Phillip
2. Systemic improvements to the custodial healthcare pathway to reduce reliance on Port Phillip Prison as a conduit for secondary and tertiary care access
3. Enhanced Risk and Escalation pathways in healthcare management systems when external health appointments are cancelled or refused
4. Consultation protocols between Health Service Provider, Justice Health, and Sentence Management Division when treatment refusal poses clinical risk, considering alternative prison pathways for hospital access