Coronial
WAhospital

Inquest into the Death of Karl Frederick Dominic HOLMES

Deceased

Karl Frederick Dominic HOLMES

Demographics

66y, male

Coroner

Deputy State Coroner Linton

Date of death

2023-01-14

Finding date

2024-04-04

Cause of death

Complications of metastatic lung adenocarcinoma, with terminal palliative care, in a man with multiple medical comorbidities

AI-generated summary

Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellent medical care from Dr S. who actively managed his investigations, specialist referrals, and supported his informed decision to refuse potentially curative treatment. Holmes rapidly deteriorated in January 2023 and was transferred to Fiona Stanley Hospital where he died. The coroner commended the medical care but identified issues: (1) delayed dental treatment despite identified need and multiple requests, and (2) failure to complete an External Movement Risk Assessment before emergency transfer, resulting in unnecessary restraints applied to a terminally ill, frail patient. The coroner noted dental care deficiencies and recommended the Department improve dental service consistency across prisons, replicating the successful model at Hakea Prison.

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

Specialties

oncologypalliative careemergency medicinegeneral practicerespiratory medicinehepatologycorrectional health

Error types

systemdelay

Drugs involved

morphinemorphinediazepamantivirals for covid-19

Clinical conditions

metastatic lung adenocarcinomahepatocellular carcinomaacute renal failurechronic obstructive pulmonary diseaseemphysemainfective exacerbation of respiratory illnessneuropathic painradiculopathyhepatic cirrhosisCOVID-19 infection

Procedures

liver biopsylung biopsyCT scanMRIradiation therapy

Contributing factors

  • Metastatic lung adenocarcinoma
  • Hepatocellular carcinoma with metastases
  • Chronic obstructive pulmonary disease
  • Acute renal failure
  • Infective exacerbation of respiratory illness
  • Patient's informed refusal of active treatment
  • Extensive emphysema
  • Multiple comorbidities

Coroner's recommendations

  1. The Department of Justice should work with the Department of Health to improve dental service provision across prisons and consider replicating the model currently in place at Hakea Prison, which has been demonstrated to be of high standard
  2. The Superintendent of Casuarina Prison should continue implementing the Local Process requiring External Movement Risk Assessments (EMRA) for all unscheduled medical escorts to be completed as soon as practicable
  3. Prison staff should receive more training on the correct application of section 5.3.1 of Commissioner's Operating Policy and Procedure 12.3 regarding restraints for terminally ill prisoners
  4. TOMS system amendments showing Terminally Ill status should continue to be utilized to assist prison officers in completing accurate EMRAs without breaching patient confidentiality
Full text
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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.

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