Deceased
Stuart William DUGAN
Demographics
70y, male
Coroner
Deputy State Coroner Linton
Date of death
2017-05-04
Finding date
2021-01-15
Cause of death
carcinoma of the lung
AI-generated summary
Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognosis, regular annual health checks were not consistently performed during his 6+ years at Acacia Prison. From December 2016 onwards, significant red flags—including haemoptysis, weight loss (>9kg), tachycardia, and chest pain—were not recognized by nursing staff or escalated appropriately. When finally referred to hospital in February 2017, diagnosis was delayed by reliance on urgent x-ray ordering rather than emergency department referral. Expert evidence suggests earlier diagnosis would not have changed outcome, but earlier hospital referral might have reduced suffering. The coroner found gaps in care fell short of community standards, with lack of follow-up on referrals and poor documentation. Acacia has since implemented proactive health monitoring, dedicated annual assessments, and improved referral tracking systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
1y · Male·Complications of acute lymphoblastic leukaemia
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
42y · Male·Ligature compression of the neck (hanging)
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.