Coroner's Court of Western Australia

Inquest into the Death of Jeremy Michael SCOTT

Inquest into the Death of Jeremy Michael SCOTT

Delivered on :14 September 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No 1

To ensure that when prisoners are referred to external agencies those referrals are managed in a timely and appropriate manner, the Department of Justice (DOJ) should consider establishing a system that alerts the Prison Health Service when such referrals are overdue.  DOJ should also consider allocating sufficient resources to enable a project team to be established to finalise the work currently being undertaken by Dr Joy Rowland in establishing a system to monitor and track these referrals.

Recommendation No. 2

The Department of Justice (DOJ) should consider amending the Health Services Policy relating to annual health reviews so that priority is given to reviewing vulnerable and older prisoners.  Further, DOJ should allocate appropriate resources to enable these annual reviews to be conducted in a timely manner.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Scott died on 3 July 2017 of metastatic rectal carcinoma.  He was 64-years of age and had been in prison since 1998.

Prison records show that Mr Scott had complained of rectal and/or anal symptoms from at least 2006 and that a prison medical officer documented that Mr Scott a long-standing history of haemorrhoids but had had declined a rectal examination.  On 17 September 2015, Mr Scott was seen by a prison medical officer and he reported feeling haemorrhoid inside his rectum on the left side “that was not very big”.  He again declined a rectal examination and no further action was taken.  Mr Scott was seen by another prison medical officer on 20 November 2016, and described feeling a large, soft mass which he assumed was a haemorrhoid.  He again declined a rectal examination and was referred to a consultant surgeon.

Although the referral to the surgeon had been marked “urgent” and there was an expectation he would be seen within 30 days, Mr Scott was not reviewed until 1 March 2017, some 100 days after the referral had been made.  Scott described a 12-month history of anal pain on defecation and intermittent bleeding.  The surgeon thought it was likely Mr Scott required treatment for an anal fissure and scheduled for sphincterotomy procedure in May 2017, although the procedure was later postponed until July 2017.

Mr Scott was seen at the prison medical centre on 26 May 2017 and he complained of constipation and urine retention.  He was described as anxious and very distressed by a prison nurse and was taken to Bunbury Regional Hospital (BRH) for review.  The registrar who saw Mr Scott noted he described “excruciating pain” and says she performed a rectal examination but found nothing of concern.  Mr Scott was given analgesia and discharged back to prison.

Following the results of blood tests on 21 June 2017, Mr Scott was taken back to BRH.  By that time, he was confined to a wheelchair and was experiencing ongoing pain.  He underwent an examination under anaesthesia on 22 June 2017, and a surgeon detected an 8 cm mass just inside his anus.  Tests confirmed that the mass was cancerous and Mr Scott was diagnosed with rectal carcinoma with liver and lung metastases.

Active treatment was ceased and on 30 June 2017, Mr Scott was transferred to the palliative care unit at St John of God Hospital, Bunbury where he remained until his death on 3 July 2017.

The Coroner made two recommendations relating to the Department of Justice’s policy on monitoring referrals of prisoners to external agencies.

The Coroner was satisfied that the supervision Mr Scott received while he was incarcerated was appropriate and that until September 2015, Mr Scott’s medical care was commensurate with community standards.  After that time, the coroner found that there several missed opportunities to diagnose the rectal cancer from which Mr Scott eventually succumbed.  With the benefit of hindsight, these missed opportunities may have deprived Mr Scott of the possibility of a cure, or at the very least, treatment that might have prolonged and/or improved the quality of his life.

Catch Words : Death in Custody : Supervision, Treatment and Care : Diagnosis be made in a timely manner by clinical staff : Improvement to health outcomes for at-risk prisoners : Recommendations : Natural Causes

Last updated: 5-Jan-2022

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