Inquest into the Death of Jeremy Michael SCOTT

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 R. 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.