Coroner's Court of Western Australia

Inquest into the Death of Lajos SZABO

Inquest into the Death of Lajos SZABO

Delivered on : 6 August 2021

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Lajos Szabo was a sentenced prisoner at the time of his death on 3 February 2019.  He had been diagnosed with terminal lung cancer and was receiving palliative care. 

There was a delay from the time when Mr Sazbo was admitted into the prison before he was properly medically examined.  On 21 November 2018 Mr Szabo presented to the medical centre with a four day history of a painful lump on the right side of his neck and a low grade temperature.  He was reviewed by a nurse and then returned the following day, where the right side of the neck was seen to have increased in size since the previous day.  An infection was suspected and he was commenced on antibiotics and given pain medication while urgent blood tests and mumps serology were requested.  Mr Szabo was reviewed by the doctor again the following day and he reported he felt the antibiotics were working and his pain and the swelling had reduced.

On 27 November 2018 Mr Szabo’s blood tests results came back and they were very abnormal.  A plan was made for further review by a doctor and the blood pathology tests were to be repeated.  Mr Szabo saw the nurse the next day for further blood samples to be taken and reported feeling some improvement.  However, the repeat blood tests on 28 November 2018 showed worsening liver function, ongoing anaemia and persistently raised CRP, white cell count and platelets.

On 29 November 2018 Mr Szabo was reviewed by the doctor again, who noted there was still soft swelling on the right side of the neck and very high inflammatory markers.  Further blood tests were taken with a medical review panel for the following week.  However, the medical officer also suggested consideration of an urgent referral to a hospital ED or urgent ultrasound of the neck if things did not improve.  On 7 December 2018, before Mr Szabo was reviewed again, a code blue occurred as Mr Sazbo complained of acute chest pain and shortness of breath.  An ECG was conducted and reviewed by a doctor, who noted his recent bloods were still abnormal with indication of infection.  It was decided he should be sent to St John of God Hospital Midland by ambulance for urgent medical review.

Mr Szabo was admitted to St John of God Hospital Midland where he underwent a CTPA which showed a cavitating mass in the upper lobe of the right lung and enlarged lymph glands in the mediastinum and neck, suggestive of a malignant process.  A lymph node biopsy was performed on 10 December 2018.  Mr Szabo was discharged back to prison on 11 December 2018 with an appointment to see his specialist in the outpatient clinic in a week.  On 13 December 2018 Mr Szabo was informed the biopsies confirmed non-small cell lung cancer.  He was offered prison counselling for support but he declined.  Mr Szabo was registered on the Department’s terminally ill register on 27 December 2018.

On 1 January 2019 Mr Szabo complained of swollen limbs and a fever.  He was transferred to SJOGH Midland.  Prison medical staff were advised that Mr Szabo had a very fast moving cancer with progressive fluid collection around the lungs and heart and peripherally.  It was noted that ongoing treatment might only be palliative and he could be expected to deteriorate quite quickly.

Mr Szabo was discharged back to prison on 3 January 2019 and, at his request, his radiotherapy was postponed for several days.  It was noted Mr Szabo was unable to walk on 5 January 2019 due to swelling of his lower legs.  Mr Szabo’s health continued to deteriorate and on 22 January 2019 he was admitted to Bethesda Hospital for end of life care.  Mr Sabo was kept comfortable until he passed away on the morning of 3 February 2019.

The Deputy State Coroner was satisfied Mr Szabo received a high level of medical care while in custody that was equal to, or above, what he would have received in the community..

Catch Words : Death in Custody : Care, Treatment and Supervision : Natural Causes

Last updated: 6-Oct-2021

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