Inquest into the Death of Mackenzie, Alexander Ronald

60y · Male·Pneumonia in a man with advanced metastatic angiosarcoma

A 60-year-old prisoner serving a life sentence died of pneumonia complicated by advanced metastatic angiosarcoma. He had two rare medical conditions: epithelioid angiosarcoma (diagnosed 2007) and aortitis. A significant radiological finding of aortic thickening consistent with peri-aortitis in 2003 was not acted upon and became lost in extensive medical records across multiple attendances. The coroner found that while individual continuity of care by a single physician could theoretically have identified these conditions earlier, the deceased's ultimate prognosis was incurable. Medical care provided was reasonable given the prison environment's constraints. Key lesson: in complex patients with multiple investigations and hospital referrals, systematic review and integration of all findings is essential to prevent diagnostic delays, even when individual investigations are appropriately ordered.