Coronial Inquest into the death of Norman Alexander HAZELGROVE
Delivered on: 20 March 2020
Delivered at: Perth
Finding of: Coroner Linton
Suppression Order: N/A
Summary: The deceased at the time of his death was a sentenced prisoner having been sentenced in 2013 to a long term of imprisonment. He had been transferred to hospital from prison when it became apparent that his death was imminent and he required palliative care.
The inquest focused primarily on the gap in the deceasedâ€™s medical care while a prisoner from the early suspicion of COPD to the later diagnosis of terminal lung cancer.
The deceased was described as being a well-mannered and courteous prisoner who abided by the rules and regulations of the prison and interacted well with his peers. When the deceased was first admitted to prison, he had no major health concerns and was not taking any medications. The deceased first reported on 13 September 2013 to a doctor and a chest examination revealed reduced breath sounds. On 17 December 2013 the deceased was reviewed again by a doctor in relation to his high blood pressure and was again encouraged to stop smoking. The deceased continued to be monitored throughout 2014. From March 2015 the deceasedâ€™s medical reviews reduced significantly and he did not have regular monitoring. It was noted that there was no follow-up of the deceasedâ€™s COPD diagnosis until he experienced respiratory difficulties on 6 May 2017.
The deceased was taken to St John of God Hospital Midland on 6 May 2017 and a chest CT scan showed a large tumour in the right lung, with collapse of the middle and right lower lobes. After further investigations the deceased was diagnosed with lung cancer. The deceased remained at hospital where treatment continued and the deceasedâ€™s medical management was discussed with him. He was eventually discharged back to Acacia Prison on 18 May 2017.
On 2 August 2017 the deceased was reviewed in the SJOG Midland Hospital Oncology Clinic and palliative chemotherapy was discussed. He declined the treatment and no further follow up was arranged. The deceasedâ€™s condition gradually deteriorated over the next few weeks. On 7Â September 2017 Palliative Care Service assessed the deceased. A suggested medication regime to manage his pain was made and on 13 September 2017 the deceased was reviewed again by the Palliative Care Service and he was commenced on more regular morphine for pain relief. A plan was made to transfer him to Bethesda Hospital Palliative Care Unit once a bed became available.
The deceased was admitted to the Palliative Care Unit of Bethesda Hospital on the morning of 17Â September 2017 and was kept comfortable until he passed away peacefully just after midnight on 18 September 2017.
The Coroner noted the Department of Justice had made some improvements to the prison health services to prompt more regular medical reviews with an emphasis on preventative health and identifying risk factors. Education had also been provided regarding appropriate response to abnormal observations through the Clinical Nurse.
Catch Words: Death in Custody : Palliative Care : Chronic Obstructive Pulmonary Disease (COPD) : Natural Causes.
Report: Norman Alexander HAZELGROVE