Inquest into the Death of Errol Warren BARTLETT

87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative care)

Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings should be included in prisoner health summaries sent from general practitioners to prison health services—the 27 ug/L result obtained pre-imprisonment was not disclosed, delaying diagnosis until May 2021 when advanced metastatic disease was present; (2) prison discharge decisions must account for limited infrastructure at prison infirmaries and the unavailability of palliative care except at specific facilities; (3) policies prohibiting restraints on terminally ill, elderly and frail prisoners with mobility issues must be rigorously enforced via documented risk assessments before restraints are applied. The coroner found that restraints applied during Mr Bartlett-Torr's hospital admission were inappropriate and violated Department policy, yet had only minor clinical impact given his imminent death.