Inquest into the Death of Matthew John PICKIN

56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with multiple comorbidities, including metastatic lung adenocarcinoma, with terminal palliative care

Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer was appropriately investigated following haemoptysis in October 2021, with timely referral to specialists and commencement of radiotherapy, chemotherapy, and immunotherapy in January 2022. Medical care was comparable to community standards and appropriately escalated to hospital specialists. The two-week delay in commencing whole-brain radiotherapy did not meaningfully impact outcome given his stage IV disease. A clinical lesson concerns restraint application: Mr Pickin was inappropriately restrained during his final hospital admission on 5 March 2022 despite being terminally ill and frail. System improvements have been implemented including terminal illness alerts in prisoner management systems and clearer guidance for prison officers regarding restraint use in terminally ill prisoners.