Inquest into the Death of Kevin John KEATH
Deceased
Kevin John KEATH
Demographics
76y, male
Date of death
2023-08-20
Finding date
2024-07-10
Cause of death
metastatic prostate cancer with terminal palliative care
AI-generated summary
Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including regular medical reviews, specialist consultations, and high-quality palliative care. One minor issue was identified: a repeat colonoscopy recommended in 2020 was not scheduled until 2022 (and subsequently cancelled due to COVID-19), attributed to his voluminous GP summary not being adequately transcribed. However, the coroner found this did not affect his clinical outcome. The coroner commended clinical staff for excellent palliative care but noted that early transfer to Bethesda Health Care would have been preferable to provide a more suitable end-of-life environment and better family access. Overall, the standard of care was equivalent to or better than community standard.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Clinical conditions
Contributing factors
- advanced metastatic prostate cancer with widespread skeletal metastases
- delayed scheduling of follow-up colonoscopy (not booked until November 2022, cancelled due to COVID-19, not performed until June 2023)
- voluminous GP health summary not adequately transcribed upon reception into custody
- delayed transfer to external palliative care facility (10 days between patient request and actual transfer)
- bed availability constraints at Bethesda Health Care
Coroner's recommendations
- COPP 6.2 (Prisoners with a Terminal Medical Condition policy) should be immediately amended to incorporate changes to policy and practice identified regarding Ministerial briefings for terminally ill prisoners, including explicit recommendations on early release under the Royal Prerogative of Mercy
- The process for Attorney General approval of prisoner early release under the Royal Prerogative of Mercy should be clarified to ensure there are no delays in the event of a recommendation to release
- Consideration should be given to improving the Casuarina infirmary facilities, which the coroner found to be dilapidated and depressing, unsuitable for delivery of end-of-life care
- Early transfer of terminally ill prisoners to external palliative care facilities such as Bethesda should be prioritised to provide appropriate end-of-life environments and facilitate family access
- Prison medical intake procedures should be improved to ensure that key medical information from voluminous GP summaries is adequately identified and transcribed into prisoner files to avoid missing routine screening or follow-up appointments
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