Coronial
WAhospital

Inquest into the Death of Terrence Alexander Penman WELLS

Deceased

Terrence Alexander Penman WELLS

Demographics

61y, male

Date of death

2018-12-12

Finding date

2022-01-05

Cause of death

metastatic oesophageal neuroendocrine carcinoma

AI-generated summary

Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attributed to missing teeth. The coroner found the medical care provided was appropriate and timely once specific swallowing symptoms were reported. A medication error in June 2018 (duplicate cholesterol medications) was unlikely to have affected the outcome but prompted system improvements. The primary deficiency identified was the Department's failure to prepare a briefing note for the Minister for Corrective Services when Wells was classified as terminally ill, which would have initiated compassionate release consideration through the Royal Prerogative of Mercy process. This occurred due to a vacant position during departmental restructuring. Early symptoms in January 2018 (neck issues) were not investigated for cancer but the coroner found this reasonable given the non-specific nature and patient attribution to known conditions.

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

Specialties

oncologypalliative caregastroenterologycardiologyendocrinologycorrectional healthemergency medicine

Error types

medicationsystemdelay

Drugs involved

pantoprazolepregabalincarboplatinetoposidemorphineinsulin

Clinical conditions

oesophageal neuroendocrine carcinomametastatic cancertype 2 diabetes mellitusischaemic heart diseaseinferior myocardial infarctionpancytopeniaanaemianeutropenic sepsisdysphagiadehydrationchronic lower back painperiodontitissensorineural hearing loss

Procedures

oesophageal stent insertionnasogastric tube insertioncentral line insertiongastroscopycomputed tomography scanblood transfusion

Contributing factors

  • advanced cancer at diagnosis
  • rapid disease progression
  • history of smoking
  • poor blood sugar control in diabetes
  • failed oxygen therapy consideration
  • medication error with duplicate cholesterol medications on 20 June 2018
  • failure to prepare briefing note for Royal Prerogative of Mercy process

Coroner's recommendations

  1. The Department should ensure that staffing arrangements are maintained for all critical roles, particularly those related to terminally ill prisoners and the Royal Prerogative of Mercy process
  2. Improvements to the EcHO electronic medical record system to limit the number of individual patient records that can be opened simultaneously to prevent medication errors similar to the duplication that occurred on 20 June 2018
  3. Consideration should be given to proactively notifying terminally ill prisoners and their families of the Royal Prerogative of Mercy process rather than relying solely on prisoners or families to initiate inquiries
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