Lingwood, Craig Steven

45y · Male·metastatic malignant melanoma

Craig Lingwood, a 45-year-old prisoner, died from metastatic melanoma in May 2011. He first complained of a suspicious mole (red, itchy, bleeding) in 2005-2006, but the prison doctor (Dr C.) assessed it as benign in August and December 2006 without performing biopsy. In February 2008, hospital dermatologist Dr E. identified it as probable melanoma and made an urgent referral to the Lesion Clinic, but this referral was lost in the system and never acted upon by the prison. When Lingwood finally saw a new prison doctor (Dr C.) in September 2008, biopsy confirmed melanoma. Excision occurred in October 2008—over two years after initial presentation. Critical failures included: inadequate tracking of urgent referrals from hospital to prison; failure to follow up the referral through hospital systems; lack of structured follow-up protocols post-excision (should have been 3-4 monthly reviews per guidelines); and no system to identify when referrals fell through cracks. Earlier intervention in 2006-2008 may have improved prognosis. Systemic deficiencies rather than individual clinician fault contributed to delays.