Inquest into the Death of Frank MIKHAIL

68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pulmonary disease

Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in a heavy smoker with COPD warrants investigation for malignancy, not just infection; (2) a chest CT should have been urgently arranged; (3) SJOG staff failed to adequately investigate or document a further haemoptysis episode at 10.45am; (4) discharge occurred without clear deterioration warning signs for prison medical staff; (5) after discharge, persistent symptoms despite antibiotics should have triggered hospital reassessment; (6) cognitive bias from previous similar presentations may have masked new pathology. Post-mortem revealed lung carcinoma with haemorrhagic lesion. Earlier admission, CT imaging, and/or hospital reassessment might have extended lifespan and improved quality of life, though prognosis remained poor.