Finding into death of MICHAEL GOLDMAN
Deceased
MICHAEL GOLDMAN
Demographics
60y, male
Date of death
2008-09-29
Finding date
2010-05-17
Cause of death
Metastatic carcinoma of the prostate
AI-generated summary
Michael Goldman was a 60-year-old prisoner at Port Phillip Prison who died of metastatic prostate cancer. He was diagnosed with prostate cancer in September 2006 and underwent brachytherapy in mid-2007. By May 2008, progressive bony metastatic disease was identified and he underwent orchidectomy at St Vincent's Hospital. He was seen by oncology in August 2008 and commenced on hormonal therapy, which failed to control the cancer. He was transferred back to St Vincent's Hospital on 25 September 2008 for palliative care and died on 29 September 2008. The coroner found he died of natural causes and that examination of medical records did not support allegations of negligence or failure to provide proper and prompt medical interventions. However, a systemic failure was identified: Justice Health failed to implement Chronic Health Care Plans for this prisoner with multiple chronic conditions, though this failure would not have affected the health outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Advanced metastatic prostate cancer with bony metastases
- Hypercalcemia from bone metastases
- Systemic failure to implement Chronic Health Care Plans
Coroner's recommendations
- That Justice Health ensure and monitor the implementation of Chronic Health Care Plans, where indicated, by all Justice Health's contracted care providers
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