Deceased
Stephen Joseph SCHIPP
Demographics
58y, male
Coroner
Coroner Nelson
Date of death
2024-05-24
Finding date
2025-11-27
Cause of death
complications of oesophageal cancer, with terminal palliative care
AI-generated summary
Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in January 2023, treated with chemotherapy and radiotherapy, but developed recurrence in January 2024 requiring palliative chemotherapy. On 23 May 2024, while in the prison's Pre-Release Unit, he vomited blood; a prison officer called for medical assistance rather than immediately calling an ambulance. Medical staff attended within 20 minutes, and he was transported to hospital where he died the following morning. The coroner found the prison officer's risk assessment reasonable and made no criticism. However, a systemic issue was identified regarding the 10-minute potential delay for medical staff to reach the Pre-Release Unit from the main prison area, particularly outside standard hours. The coroner noted an oversight in not scheduling a recommended PET scan but found this did not materially prejudice his care. Overall, the coroner found the medical treatment and supervision satisfactory, though the Department was encouraged to review nursing resource allocation at the prison.
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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