Inquest into the death of Michael Sanderson

53y · Male·Metastatic pancreatic carcinoma

Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed diagnosis by six weeks; (2) adverse blood results were never explained to the inmate, preventing informed decision-making about diagnostic imaging; (3) cancer diagnosis obtained on 28 September 2022 but next-of-kin consents for health information sharing were not completed until 7 October 2022, creating 10-day communication blackout with family in remote location; (4) no clinician proactively contacted family after transfer to Prince of Wales Hospital emergency department; (5) inadequate systems for documenting and communicating approved end-of-life visit conditions to guards resulted in authorised items being refused and visits being curtailed. While earlier diagnosis may not have changed medical outcome, it would have enabled extended family contact, earlier palliative care, and exploration of early release options.