Coroner's Finding: SFYRIS Michael

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 21st day of March 2019 and the 14th day of May 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Michael Sfyris.

The said Court finds that Michael Sfyris aged 50 years, late of Yatala Labour Prison, Peter Brown Drive, Northfield, South Australia died at the Royal Adelaide Hospital, North Terrace, Adelaide, South Australia on the 5th day of April 2016 as a result of carcinomatosis due to metastatic, poorly differentiated renal cell carcinoma unclassified (sarcomatoid-type). The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for Inquest 1.1. Michael Sfyris died on 5 April 2016 at the Royal Adelaide Hospital. He was 50 years old. An autopsy was performed and the cause of death given by the pathologist was carcinomatosis due to metastatic, poorly differentiated renal cell carcinoma unclassified sarcomatoid type1, and I so find.

1.2. Mr Sfyris' death was a death in custody within the meaning of that expression in the Coroners Act 2003 and this inquest was held as required by section 21(1)(a) of that Act.

2. Mr Sfyris’ medical care whilst in custody 2.1. Mr Sfyris had suffered testicular cancer as a younger man but it appears that this was treated with chemotherapy resulting in an apparent cure. On 28 July 2015 Mr Sfyris presented to the Yatala prison infirmary complaining of abdominal pain, coughing and 1 Exhibit C2a

wheezing. While this presentation was thought to be a respiratory infection and antibiotics were prescribed, the medical officer referred him to the Royal Adelaide Hospital for a pelvic, chest and abdominal CT scan. It appears that this was done because of the past medical history of testicular cancer. The imaging was undertaken at the Royal Adelaide Hospital the following month, and was reported on by the Radiology Department at the Royal Adelaide Hospital on 2 September 2015.

2.2. Ms Elizabeth Sloggett is the South Australian Prison Health Service Nurse Manager Facilitator. She stated that the usual practice once radiology reports are received is for the administrative support officer to place the results in the medical officer's basket for review and signing and then for results to be placed in the health record of the prisoner.

2.3. The report in this case did not make its way in to Mr Sfyris' file. Ms Sloggett explained this and acknowledged that it was an unsatisfactory state of affairs. It caused a delay in the review of the report of two and a half months. It finally turned up on 11 December

2015. The prison health system has been changed to enforce an immediate follow-up on results for tests undertaken at external institutions.

2.4. The radiology report once received in December of 2015 stated that Mr Sfyris' chest was clear, although there were some emphysematous changes. In relation to the pelvis and abdomen CT, the report revealed a 5cm right-side adrenal cortical cystic lesion.

There were no ascites or peritoneal abnormalities. No specific abnormality was found, but the radiologist recommended an ultrasound or an historical comparison image.

2.5. The Prison Health notes reflect that over the next month Mr Sfyris saw the nurse twice because he was feeling unwell. He booked in to see the medical officer on 23 December 2015, but this did not occur due to the Department for Correctional Services escort being unable to bring medical officers in. It was rebooked for January 2016.

2.6. On 21 January 2016 Mr Sfyris saw a prison medical officer and at that time he described lower abdominal pain radiating down the groin which had been present for the last two weeks. He was having trouble with his oral intake and suffering hot and cold flushes.

The scan from the previous September was considered by the medical officer. There were differential diagnoses of renal colic or right-sided diverticulitis. The plan was to provide analgesia as needed and for a full blood examination to be done.

2.7. The following day Mr Sfyris re-presented to the health clinic with an increase in his pain and an ambulance was called. Mr Sfyris was taken to the Royal Adelaide Hospital and underwent a further CT scan of his abdomen and pelvis and this was compared to the previous scan. The new imagery revealed a right renal mass extending to his urethra causing an obstruction and displacing the renal vein. There were metastases in both the left adrenal gland and the lungs, and there were ascites and chest wall lumps as well.

2.8. Royal Adelaide Hospital consultant oncologist Dr Tan described Mr Sfyris' cancer as stage four incurable and terminal with an unknown primary source. Dr Tan was Mr Sfyris' treating oncologist from this presentation until his death.

2.9. It was Dr Tan's opinion that Mr Sfyris had a life expectancy of between nine months and two years. He said that Mr Sfyris was not keen for active therapy to treat the cancer but wanted to maintain his quality of life in order to spend time with his family once he was paroled. He refused any curative treatments and opted only for pain management.

2.10. Mr Sfyris was returned to Yatala Labour Prison following discharge from the Royal Adelaide Hospital on 30 January 2016. The notes reflect that he presented to the infirmary the following day stating that he had terminal cancer and required an increase in his analgesia as the current regime was inadequate. The case notes reflect that his pain management requirements were stepped up and this was done in consultation with the Drugs of Dependence Unit, with the use of opioids.

2.11. It was suggested to Mr Sfyris on a number of occasions that due to his high level of analgesia requirements he be admitted to the infirmary at Yatala Labour Prison. He declined this offer because he preferred to remain within his division.

2.12. He indicated to both Prison Health and clinicians at the Royal Adelaide Hospital that he did not wish to have active treatment until he was released on parole. Mr Sfyris' condition rapidly declined. Dr Tan said that this decline was more rapid than he had expected, although he added that Mr Sfyris was not receiving any active treatment.

2.13. On 1 March 2016 Mr Sfyris refused to attend an outpatients appointment at the Royal Adelaide Hospital or oncology review appointments. After having the risks explained to him, he signed an authority for refusal of treatment. On 5 March 2016 he refused to go to hospital and signed another authority for the refusal of treatment. He did however continue to access medication at the Yatala Labour Prison infirmary, but was not

willing to admit himself there for assistance with keeping his pain management under control.

3. Mr Sfyris’ decline in health and ultimate death 3.1. On 29 March 2015 Mr Sfyris collapsed. He had a distended abdomen and agreed to be transported to the Royal Adelaide Hospital. Once there he had a number of litres of fluid drained from his peritoneal cavity to reduce the swelling and associated pain of the tumours. He finally agreed to commence a chemotherapy drug called Pazopanib which is a multitargeted receptor, a tyrosine kinase inhibitor that blocks tumour growth and inhibits the growth of new cancerous blood cells. This was the treatment that Dr Tan had offered Mr Sfyris some months prior. However, by this stage the disease was so advanced that it did not have any positive effect and was actually having a detrimental effect on Mr Sfyris so it was ceased 48 hours later.

3.2. Efforts were made to bring about urgent consideration of his parole. This occurred just before he died, and the Parole Board records reflect what was done in order to have that fast tracked. Mr Sfyris died at 1800 hours on 5 April 2016, having been paroled four hours before.

4. Conclusion 4.1. I am concerned about the delay in Prison Health acting on the radiology report from September 2015. As conceded by Ms Sloggett, the misplacing of the radiology report was not in accordance with usual practices. She could only speculate about the reasons for the report not being available. This delay was then compounded by the delayed medical review because escorts were not available over a period of two months.

4.2. This is a disgraceful state of affairs. It reflects incompetence in the management of patient records on the one hand, and mismanagement of the prison on the other. The lack of escorts presumably reflected one of the customary industrial disputes within the Department for Correctional Services. It meant that between September 2015 and January 2016, the results of the CT were not reviewed or discussed with Mr Sfyris.

4.3. The question then is would a timely review of the report have brought about a different outcome. As it happens, it seems that the delay had little bearing on Mr Sfyris’ eventual death according to Dr Tan.

4.4. Furthermore the findings of the radiology report, were non-specific. They did not suggest cancer. When the medical officer did review the scans in January 2016 no immediate action was taken other than to order the blood tests. Dr Tan observed that when he diagnosed the metastatic cancer, Mr Sfyris chose not to have active treatment, choosing to wait until he was released on parole. Dr Tan thought that even with active treatment commencing in January 2016 Mr Sfyris would not have been cured. Also, there was no primary source for the cancer and it was very rapidly progressing.

4.5. All of that is of course no excuse for these lamentable failures in the proper management of Mr Sfyris’ treatment by the prison system.

4.6. I have no recommendations to make in this matter.

Key Words: Death in Custody; Prisoner; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 14th day of May, 2019.

State Coroner Inquest Number 17/2019 (0629/2016)