Inquest into the Death of Kevin George HOWLETT

Contributing factors

• 5-month delay between identification of AAA on X-ray (August 2021) and confirmatory imaging (February 2022)
• failure to indicate urgency when requesting abdominal ultrasound despite large aneurysm size (8.7 cm)
• failure to add AAA to patient's Active Problem List in electronic health record
• ultrasound request provided no indication of size or urgency to radiology department
• delayed reporting and communication of imaging results (reports not sent from hospital to prison until 18 February, not uploaded to EcHO until 21 February, 2 days before collapse)
• asymptomatic presentation between August 2021 and February 2022 (no clinical trigger for escalation)
• imaging triaging system not recognising high-risk lesion due to non-urgent classification
• COVID-19 pandemic impact on health service capacity
• limited capacity of radiology department (240,000 examinations annually)
• prison health officer may not have recognised the high-risk nature of an 8.7 cm AAA

Coroner's recommendations

1. Department of Justice to carefully consider suggestions in the FSH Report about potential improvements to imaging services offered to prisoners
2. Explore options for sharing prisoner imaging workload across Health Service Providers with tertiary facilities providing imaging to patients in prisons within their catchment area
3. Consider dedicated equipment and resources to support the prison system and ensure efficient and sustainable imaging service equivalent to general community
4. Actively explore feasibility of mobile imaging service for correctional facilities (WA Health Service Improvement Unit study)
5. Address legal and policy issues preventing use of existing X-ray machines at Casuarina and Hakea prisons for routine imaging
6. Continue education for prison medical officers regarding importance of updating Active Problem List in EcHO
7. Ensure templates used for admissions and care plan visits include prompts for updating Active Problem List
8. Continue implementation of electronic receipt of imaging reports via HealthLink to reduce delays
9. Implement new template for rapidly adding contact details of requesting doctor to imaging requests to ensure urgent results can be communicated immediately