Coronial
WAhospital

Inquest into the Death of Jeremy Michael SCOTT

Deceased

Jeremy Michael SCOTT

Demographics

63y, male

Coroner

Coroner Jenkin

Date of death

2017-07-03

Finding date

2021-09-14

Cause of death

metastatic rectal carcinoma

AI-generated summary

Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly attributed to haemorrhoids. Key missed diagnostic opportunities occurred in September 2015 (Dr Chuka—patient declined rectal examination), November 2016 (Dr Thillainathan—referral omitted mention of palpable mass, 100-day delay to surgical review), March 2017 (Dr Hendry—external examination only, no rectal examination), and May 2017 (ED assessment missed large rectal mass despite examination). Annual health reviews, faecal occult blood testing, and weight monitoring were not performed. Had colonoscopy been offered and accepted in 2015, tumour may have been curable; if diagnosed in 2016-2017, treatment might have prolonged life and reduced suffering. The coroner identified systemic failures in referral tracking, communication between clinicians, and prison health screening protocols. Clinicians must actively investigate red-flag symptoms rather than accept patient self-diagnosis of benign conditions.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general surgerycolorectal surgeryemergency medicinecorrectional healthpalliative carepathology

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

metastatic rectal carcinomarectal cancer with hepatic metastasesanal fissurehaemorrhoidsliver failure secondary to metastatic diseasehuman papillomavirus infection (HPV genotypes 16 and 18)adeno-squamous carcinoma of rectum

Procedures

rectal examinationcolonoscopy (not performed)examination under anaestheticbiopsy

Contributing factors

  • failure to refer for colonoscopy in September 2015 despite patient report of rectal lump and pain
  • assumption by multiple clinicians that symptoms were benign (haemorrhoids, anal fissure) without adequate investigation
  • 100-day delay between referral to surgeon and first appointment (referred 23 November 2016, seen 1 March 2017) with no system to monitor overdue referrals
  • referral communication omitted key finding of palpable rectal mass
  • patient refusal of rectal examinations not managed with offer of examination under sedation/anaesthesia
  • incomplete rectal examination by registrar in ED on 26 May 2017 due to patient pain and inexperience
  • failure to perform annual health reviews 2015-2017
  • failure to perform faecal occult blood testing
  • failure to monitor weight loss over time
  • lack of systematic follow-up for overdue specialist referrals in prison health system
  • no documentation of risks when patient declined examination
  • external examination only by surgeon on 1 March 2017 despite patient declining internal examination

Coroner's recommendations

  1. To ensure that when prisoners are referred to external agencies those referrals are managed in a timely and appropriate manner, the Department of Justice (DOJ) should consider establishing a system that alerts the Prison Health Service when such referrals are overdue. DOJ should also consider allocating sufficient resources to enable a project team to be established to finalise the work currently being undertaken by Dr Joy Rowland in establishing a system to monitor and track these referrals.
  2. The Department of Justice (DOJ) should consider amending the Health Services Policy relating to annual health reviews so that priority is given to reviewing vulnerable and older prisoners. Further, DOJ should allocate appropriate resources to enable these annual reviews to be conducted in a timely manner.
Full text
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