Inquest into the Death of Frank MIKHAIL

Contributing factors

• failure to admit for investigation of haemoptysis at St John of God Hospital on 29 January 2023
• inadequate assessment and documentation of haemoptysis episode at 10.45am on 29 January 2023
• discharge from SJOG without clear warning signs or clinical deterioration criteria communicated to prison medical team
• failure to arrange urgent chest CT scan at Acacia after 8 February 2023
• failure to transfer back to SJOG for reassessment when pneumonia symptoms persisted despite antibiotic therapy
• cognitive bias from multiple similar presentations masking new pathology
• severe underlying comorbidities (COPD, concurrent COVID-19 infection, immunocompromise)

Coroner's recommendations

1. Enhanced clinical decision-making regarding admission of patients presenting with haemoptysis, particularly those with significant risk factors such as heavy smoking history and severe COPD
2. Improved documentation and escalation procedures when patients report or develop haemoptysis while under medical observation
3. Clearer discharge summaries that specifically outline warning symptoms and clinical deterioration criteria, particularly for patients with multiple comorbidities being returned to custodial settings
4. Development of protocols to ensure that urgent investigations (such as CT imaging) are expedited when ordered for patients with clinical features suggestive of malignancy
5. Systems to prevent cognitive bias in clinical assessment when patients present with multiple similar episodes prior to acute pathology
6. Enhanced communication protocols between hospital and custodial medical services regarding follow-up requirements and escalation triggers