Inquest into the Death of Reginald Brian O'Neill
Deceased
Reginald Brian O'Neill
Demographics
45y, male
Date of death
2003-12-06
Finding date
2005-06-30
Cause of death
Intra Abdominal Haemorrhage Associated with Metastatic Carcinoma of the Oesophagus
AI-generated summary
Reginald Brian O'Neill, a 45-year-old sentenced prisoner at Karnet Prison Farm, died from intra-abdominal haemorrhage associated with metastatic oesophageal carcinoma on 6 December 2003. In late November 2003, he presented with upper abdominal pain and jaundice. Dr G. appropriately investigated with blood tests and ultrasound, becoming concerned by results and urgently referring him to Fremantle Hospital on 28 November. At hospital, he was initially treated for suspected pulmonary embolus with heparin, which caused gastrointestinal haemorrhage. Advanced metastatic cancer with poor prognosis was confirmed. He died in early December with family present. The coroner found the death arose by natural causes and found no significant deficiencies in his medical care. Issues noted included inadequate communication protocols between hospitals and prison authorities regarding custody procedures, and the deceased's access to methanol while incarcerated, though these did not contribute materially to his death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Metastatic oesophageal carcinoma with spread to liver and lymph nodes
- Complications from heparin therapy for suspected pulmonary embolus
- Gastro-intestinal haemorrhage
- Severe renal failure
- Poor prognosis at time of hospital admission
Coroner's recommendations
- Establish protocols between prison authorities and treating hospitals regarding supervision and care of prison patients
- Hospitals caring for custodial patients must be made aware of required death in custody protocols to protect themselves and their staff from criticism
- Effective communication protocols must be established between hospitals and prison administrators regarding custody requirements and procedures for deaths in custody
- Prison authorities should ensure Police Prison Unit is promptly notified of deaths and that forensic examination of the scene can occur appropriately
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