Inquest into the Death of Jeremy Michael SCOTT

63y · Male·metastatic rectal carcinoma

Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly attributed to haemorrhoids. Key missed diagnostic opportunities occurred in September 2015 (Dr C.—patient declined rectal examination), November 2016 (Dr T.—referral omitted mention of palpable mass, 100-day delay to surgical review), March 2017 (Dr H.—external examination only, no rectal examination), and May 2017 (ED assessment missed large rectal mass despite examination). Annual health reviews, faecal occult blood testing, and weight monitoring were not performed. Had colonoscopy been offered and accepted in 2015, tumour may have been curable; if diagnosed in 2016-2017, treatment might have prolonged life and reduced suffering. The coroner identified systemic failures in referral tracking, communication between clinicians, and prison health screening protocols. Clinicians must actively investigate red-flag symptoms rather than accept patient self-diagnosis of benign conditions.