Coroner's Court of Western Australia

Inquest into the Death of Robert Charles CRAIG

Inquest into the Death of Robert Charles CRAIG

Delivered on : 29 September 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

To ensure the accuracy of notes and treatment plans recorded following multidisciplinary team meetings (MDT) held at Fiona Stanley Hospital, MDT notes should be taken by a suitably experienced clinician or health practitioner.  Where this is not possible, MDT notes should be checked by a suitably experienced clinician prior to being circulated.

Recommendation No. 2

To ensure that referrals are triaged appropriately and in a timely manner, the e-Referral system used at Fiona Stanley Hospital should be modified to include a text box requiring the referring clinician to state the reason for the referral and, in general terms, the nature of the treatment or service being requested.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Craig died at Bethesda Health Care (BHC) on 31 January 2018, from advanced lung cancer and advanced mouth cancer.  He was 73 years of age.  Mr Craig had an extensive medical history which included: colon cancer, chronic obstructive pulmonary disease, heart disease, cerebral atrophy, osteoarthritis, depression, anxiety and post-traumatic stress disorder relating to previous military service and was a sentenced prisoner at the time of his death.

Following a history of toothache and jaw pain, Mr Craig was diagnosed with oral cancer in January 2017 and further scans identified he also had lung cancer.  He was referred to Fiona Stanley Hospital (FSH) where he underwent surgery to remove the tumour from the floor of his mouth and received radiotherapy to treat his lung cancer.  However, due to a breakdown in communication between clinics within FSH, Mr Craig did not receive the most appropriate form of chemotherapy to maximise radiotherapy for his lung cancer, nor did he receive radiotherapy and/or chemotherapy following the surgical removal of his oral cancer.

The errors in Mr Craig’s treatment were eventually detected on 18 July 2017, by which time it was too late for him to undergo post-operative radiotherapy for his oral cancer.  Instead, Mr Craig was referred for palliative chemotherapy for his lung cancer.

On 25 January 2018, Mr Craig’s condition deteriorated and he was transferred to BHC the following day for end-of-life care.  He died there in the presence of family members on 31 January 2018.

Although the coroner was satisfied that the supervision Mr Craig received during his incarceration was appropriate, the coroner found that Mr Craig’s cancer treatment was suboptimal and not in accordance with his treatment plan.  The coroner noted that since Mr Craig’s death there have been a number of procedural improvements at FSH and that there is a greater awareness of the need for vigilance in complex cases like Mr Craig’s.  The coroner made two recommendations aimed at further enhancing the management of cancer patients at FSH.

Catch Words : Death in Custody : Management of Multi Medical Issues : Multidisciplinary Team : eReferrals : Natural Causes


Last updated: 15-Nov-2021

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