Deceased
Constantinas PAPAKOSTAS
Demographics
66y, male
Coroner
Coroner King
Date of death
2011-12-11
Finding date
2015-08-28
Cause of death
carcinomatosis complicated by recurrent sepsis and multisystem failure in a man with renal cell carcinoma
AI-generated summary
A 66-year-old man with renal cell carcinoma died in hospital from carcinomatosis with sepsis and multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recurrence and negative infection workup. A prison doctor (Dr Hames) initially recognised the need for ultrasound but failed to arrange it, becoming distracted by concurrent findings of diabetic nephropathy. The tumour, likely present in 2005, was not detected until 2008 at 9cm diameter. Earlier imaging would probably have identified it at a smaller, potentially curable stage. Additional systemic delays included a lost ultrasound report in 2008 and delayed follow-up of a pulmonary nodule in 2010. The coroner found treatment and care inadequate, though acknowledged difficult working conditions and inefficient medical records systems then in place.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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Frank Kenneth Major, a 75-year-old prisoner with metastatic prostate cancer and end-stage COPD, died of natural causes in October 2021. The coroner found his overall medical care during incarceration was excellent and co…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
52y · Male·multiple organ failure and pulmonary thromboemboli complicating generalised seps…
A 52-year-old man with longstanding refusal of medical care presented with severe cellulitis, sepsis, and previously undiagnosed heart failure secondary to sleep apnoea. He lacked capacity to consent to treatment due to …
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