Coroner's Finding: MILLER Franklin Delano

58y · Male·metastatic adenocarcinomatosis with unknown primary source

A 58-year-old prisoner died of metastatic adenocarcinoma with unknown primary. In September 2006, significantly abnormal liver enzymes (GGT 2093) and hyperglycemia were detected. A December 2006 ultrasound identified an indeterminate liver lesion. Rather than pursuing specialist referral or further investigation as recommended, the treating GP adopted a 'wait and see' approach with repeat imaging planned for 6-12 months, citing the patient's reluctance to travel to Adelaide. No documentation of this refusal was recorded. The patient was not explicitly counselled about cancer as a possibility. By June 2007, he presented with metastatic cancer throughout his liver, bones and spine—by which time curative treatment was impossible. An independent oncologist opined the death was potentially preventable had the liver lesion been promptly investigated in 2006. Key failures: inadequate communication of risk, lack of documentation of patient refusal, passive acceptance of patient reluctance without firm advocacy, and inadequate continuity of care in the prison health system.