Deceased
Robert Allan EXELL
Demographics
55y, male
Coroner
Deputy State Coroner Linton
Date of death
2022-06-30
Finding date
August 2024
Cause of death
Complications of liver cirrhosis and hepatocellular carcinoma in a man with multiple comorbidities with terminal palliative care
AI-generated summary
Robert Exell, a 55-year-old Aboriginal man, died from complications of liver cirrhosis and hepatocellular carcinoma while in custody. He had chronic hepatitis C and alcohol-related liver disease since at least 2012. Key clinical gaps included a 12-month delay in his initial medical review after re-admission to prison in June 2019, and delayed investigation of his liver disease until late 2020. Although earlier detection might have enabled sooner hepatitis C treatment, the coroner found it would likely only have delayed rather than prevented death, given advanced cirrhosis and subsequent hepatocellular carcinoma diagnosis. Once terminal status was recognised, Mr Exell received appropriate palliative care. The coroner noted improvements have since been made to prison medical continuity and nurse triage processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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Russell Graham Penny, a 56-year-old Aboriginal man, died from complications of advanced chronic liver disease with hepatocellular carcinoma while imprisoned at Casuarina Prison. He had a long history of hepatitis C and c…
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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 excellen…
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Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…
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