Coroner's Finding: DODSON Edward Leonard

78y · Male·metastatic malignancy (unknown primary) with contributing right-sided heart failure

Leonard Edward Dodson, aged 78, died in custody from metastatic liver cancer (unknown primary) with contributing right-sided heart failure. He had prostate cancer diagnosed in 2010 via elevated PSA (20ng/ml) but was not adequately investigated until January 2013 due to a failed appointment in March 2011 (no doctor available) and subsequent 18-month delay. A urologist visited Port Lincoln monthly but Dodson was not referred until October 2012. CT imaging in March 2013 revealed liver metastases; prostate cancer entered remission with hormone therapy but liver disease progressed, indicating a different primary source (possibly bowel). No colonoscopy or liver biopsy was performed to identify the primary cancer. Expert opinion suggests earlier investigation of liver metastases might not have significantly extended life given advanced disease, but communication about investigation importance and documentation of refusals were inadequate.