Inquest into the death of Melville Schrader

76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tumour

A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2015 and November 2017, he submitted multiple self-referral forms reporting abdominal pain, weight loss (15kg), diarrhoea, and family history of bowel cancer. Despite nursing staff appropriately identifying need for GP review and colonoscopy, administrative failures prevented proper waitlisting. Expert oncologists confirmed earlier diagnosis (potentially December 2015) was achievable and would likely have improved his survival and quality of life. The coroner found the prison health service response 'seriously deficient' and acknowledged by the Justice Health Network. Systemic failures included errors in patient administration system data entry, poor communication between nursing staff and doctors, and inadequate follow-up mechanisms. While cure was unlikely given metastatic disease, earlier treatment would have reduced his suffering and potentially extended survival.