Coroner's Finding: Sears, James Frank

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INQUEST INTO THE DEATH OF JAMES FRANK SEARS [2025] SACC 16 Inquest Findings of his Honour State Coroner Whittle 3 June 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a 53-year-old man who died as a result of advanced skin cancer while incarcerated at the Yatala Labour Prison. The cancer was detected following the excision of a large mole on his arm. The inquest explored the decisions made in relation to further excision and lymph node dissection following diagnosis and discussion at a Multi-Disciplinary Team meeting.

Held:

1. James Frank Sears, aged 53 years of Yatala Labour Prison, died at Yatala Labour Prison on 1 March 2021 as a result of disseminated malignant melanoma.

2. Circumstances of death as set out in these findings.

Recommendations made.

Counsel Assisting: MS S GILES Hearing Date/s: 28/02/2024 Inquest No: 10/2024 File No/s: 0426/2021

INQUEST INTO THE DEATH OF JAMES FRANK SEARS [2025] SACC 16 Introduction and cause of death James Frank Sears was born on 30 May 1967 and died on 1 March 2021, at the age of 53 years, in the Health Centre of Yatala Labour Prison (Yatala).

A pathology review was undertaken at Forensic Science SA on 3 March 2021 by Dr Alexandra Yuill, medical practitioner, from which Mr Sears’ cause of death was stated to be ‘disseminated malignant melanoma’.1 I accept Dr Yuill’s opinion and find this to have been the cause of Mr Sears’ death.

Reason for inquest As Mr Sears was serving a period of imprisonment at the time of his death, his death is a death in custody and thus this is a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

Family background Mr Sears was born to Raelene Margaret Hill and Trevor Duthie. Ms Hill then married Sidney Frank Charles Sears who adopted Mr Sears. Mr Sears had six biological siblings and two adoptive siblings.

Mr Sears was a ward of the state several times as a child. He spent some years of his childhood in foster care and some living with his mother and adoptive father.

Mr Sears attended Salisbury North West Primary School and Salisbury High School, which he left when in Year 9.

Mr Sears married Fiona Sears (née Griffith) in the 1980s. They had three children together before eventually separating.

After his separation, Mr Sears resided with Janet Milera. They married in 2001 and had two children together.

Ms Milera and Mr Sears separated in 2010 but did not divorce until December 2018.

They remained friends, and Ms Milera would speak with him regularly whilst he was in prison.

Mr Sears was engaged to Rosemary Freshney prior to his imprisonment and the couple remained together until his death.

Mr Sears’ employment history included working in abattoirs, the construction industry, a clothing business with a school friend selling clothes in Aboriginal communities, then for Bridgestone. At Bridgestone he was injured when his ankle was crushed by a machine.

1 Exhibit C2a

[2025] SACC 16 State Coroner Whittle Following an ankle reconstruction, he suffered ongoing pain and arthritis, rendering him unable to work.

Immediately prior to his imprisonment, Mr Sears was a disability pensioner.2 Admission to prison Mr Sears was admitted to prison on 21 February 2018, before being sentenced. He was initially housed at Yatala before being transferred to the Mount Gambier Prison on 26 February 2018.

On 4 April 2018 Mr Sears was sentenced to 10 years imprisonment with a non-parole period of four years.

According to the affidavit of Dr Daniel Pronk, Medical Director of the South Australian Prison Health Service (SAPHS), Mr Sears weighed 140kg at the time of his admission and had a medical history of asthma, chronic obstructive pulmonary disease, hypertension, anxiety, depression, gastric reflux and chronic hip and leg pain.

Mr Sears was not known to be a user of illicit substances but was a smoker.3 Circumstances leading to death On 18 November 2019 Mr Sears was seen by a nurse who recorded in his file that he had a large black mole on his arm measuring 3cm x 4cm with dried blood on the surrounding skin. The nurse noted the mole was cleaned with saline and dressed.

A request was submitted for Mr Sears to be reviewed by a doctor the following day. The notes indicate that Mr Sears had knocked the mole over a week earlier, which caused it to bleed. The mole had not been mentioned in previous SAPHS medical notes.

On 19 November 2019 the mole was excised by a doctor at Mount Gambier Prison. It was described as a lesion on Mr Sears’ left upper arm which was ‘fungating’, ‘very vascular’ and 6cm x 4cm in size.4 The wound was sutured and dressed.

Upon testing of samples from the lesion, it was found to be a melanoma which was 'extending to all margins' and would require wider excision.

On 3 December 2019 Mr Sears underwent a CT scan of his chest, abdomen and pelvis.

The scan noted two suspicious enlarged left axillary lymph nodes and a solitary enlarged right inguinal node.5 A note in Mr Sears’ file indicated his body mass index was too high for him to be treated locally, and he would need to be treated in Adelaide. He was transferred to Yatala on 11 December 2019.

2 Exhibit C9 3 Exhibit C7 at [4] 4 Exhibit C10, volume 1 5 Exhibit C10, volume 1

[2025] SACC 16 State Coroner Whittle On 31 December 2019 a dermatology medical officer at the Royal Adelaide Hospital (RAH) reviewed Mr Sears and, based on the results of the CT scan earlier that month, assessed the disease as a clinical Stage III. The plan was for Mr Sears to have a core needle biopsy, cancer staging with a whole-body PET scan, and left axillary lymph node dissection to confirm that the staging remained at Stage III. Stage III melanoma with this treatment plan meant that the disease was ‘potentially curable’.6 A further review by the RAH Oncology Unit on 14 January 2020 confirmed the disease was at Stage III. Wide local excision was suggested.

On 15 January 2020 Mr Sears was transferred back to Mount Gambier Prison.

The test results for Mr Sears were discussed at the RAH's Multi-Disciplinary Team (MDT) meeting on 21 January 2020.

Following the MDT meeting, it was documented by Dr Matthew Sang-Woo Cho that, on 21 January 2020, Mr Sears' case was discussed at the MDT and that lymph node dissection and wide local excision were recommended. It was recorded by Dr Cho that Mr Sears was to be discharged from Dermatology and would have ongoing follow up by surgical or medical oncology.7 A document entitled ‘Clinical Summary Melanoma Multi-Disciplinary Meeting’, also dated 21 January 2020, stated under the heading of 'Discussion': ‘Re-present as apparent Stage 3D disease and re-present at next Melanoma MDT to determine if disease is now completely resected.’8 This note clearly contemplated that further surgery should occur before the next MDT, at which the case should be re-presented and discussed. A booking was not made for the surgery following that meeting. There are no further RAH records until 5 May 2020.

Mr Sears was transferred back to Yatala in April 2020.

On 5 May 2020 it was noted at the RAH Surgical Oncology clinic review by Dr Geoffrey Wong, a medical officer of the RAH Surgical Oncology Unit, that: ‘Seen at Surgical Oncology 14/01/20 and has not been seen since Melanoma MDT in January 2020’ and ‘There has been local and regional progression of melanoma clinically. Metastatic disease requires exclusion.’9 Dr Wong arranged for urgent cancer staging CT and PET scans. On 15 May 2020 Dr Wong reviewed the findings, which showed extensive metastatic melanoma.

6 Exhibit C6 at [6] 7 Exhibit C10, volume 1 8 Exhibit C14, Annexure A 9 Exhibit C10, volume 2

[2025] SACC 16 State Coroner Whittle At the RAH MDT on 26 May 2020 the delay in Mr Sears’ treatment was examined.

Treatment options were discussed with Mr Sears but, at this stage, his treatment was to be palliative.

CT scans performed over the next few months showed progression of disease despite various treatments, including with chemotherapy drugs, immunotherapy drugs, and radiotherapy.

Mr Sears was admitted to the RAH on 15 January 2021 as he was breathless. A pleural tap was commenced, but a pleural drain was then required due to fluid continuing to re accumulate. The disease was progressing, and it was noted that there were new bony metastases in his right femur. Consideration was given to pinning the femur; however, he was too unwell for surgery. He returned to Yatala and was housed in the Health Centre of the prison.

On 9 February 2021 he returned to the Emergency Department of the RAH with a cough and fever. He was prescribed antibiotics for pneumonia and was returned to Yatala.

Mr Sears remained at the Health Centre where his condition continued to worsen. At approximately 7:40am on 1 March 2021 his breathing became laboured, and he became unresponsive. Mr Sears stopped breathing. CPR was not commenced due to his having a 7-step pathway with no CPR.

Mr Sears’ death was certified by SAPHS Medical Officer, Dr Mahima Singh, at 8:50am.10 Failure to excise following Multi-Disciplinary Team meeting in January 2020 Despite the recommendation made at the MDT meeting held on 21 January 2020 that Mr Sears have a wide local excision and lymph node dissection, this did not occur. By the time of the RAH Surgical Oncology review in May 2020, Mr Sears had extensive metastatic melanoma, and he was palliated. I adjourned the inquest at the conclusion of Counsel Assisting’s opening submissions on 28 February 2024, for the purpose of investigating why the recommended wide local excision and lymph node dissection did not occur and whether, had it occurred in January 2020 as recommended, Mr Sears’ death may have been prevented.

An affidavit was obtained from Dr Cho,11 who made the entry in the case notes following the MDT meeting in January 2020. Dr Cho was, at that time, employed as a dermatology trainee/registrar at the RAH. He was in that position from February 2019 to February

2020. He now works in private practice. Dr Cho stated that in December 2019 he diagnosed Mr Sears as having thick melanoma with possible lymph node involvement and arranged for him to have an ultrasound guided biopsy of the lymph node on 7 January 2020 and a PET CT scan to help stage the disease, which he had on 6 January 2020. He stated that the severity of the melanoma was something beyond the treatment that a dermatologist could provide and required surgical input. Therefore, on 31 January 2019 he personally went to the General Surgical Outpatient Clinic, with which they shared a clinic space, and discussed the case with Dr Coventry, a senior consultant surgeon. An appointment was arranged with the surgical team for 14 January 2020. Mr Sears was 10 Exhibit C10, volume 3 11 Exhibit C13

[2025] SACC 16 State Coroner Whittle referred to the General Surgical Oncology team to complete ongoing investigation and management. It was also planned for the case to be discussed at the Melanoma MDT meeting on 21 January 2020.

As arranged, Mr Sears was seen by a member of the surgical team in the General Surgical Oncology Outpatient Department on 14 January 2020. The surgeon who saw Mr Sears has recorded confirmation of the previous findings and agreed with the presence of thick melanoma with metastatic spread to left axillary lymph node. He noted there was ‘low uptake of bilateral inguinal nodes’ and that ‘no convincing evidence of distant metastatic disease is seen’.12 Hence the surgeon documented to follow up with further investigation, by ultrasound of groins and fine needle aspiration, of any suspicious nodes and for review in two weeks.

Mr Sears’ case was discussed at a Melanoma MDT meeting on 21 January 2020. On that date Dr Cho made his final documentation as a member of the dermatology team in Mr Sears’ medical record. He noted the results of the recent investigations performed since his initial review on 31 December 2019, he confirmed that the Mr Sears had been seen at the General Surgical Oncology Outpatient Department on 14 January 2020, and he documented the discussion and plans from the Melanoma MDT.

Dr Cho stated that as Mr Sears was already referred to the General Surgical Oncology team, and had already been seen by the team in their clinic on 14 January 2020, with established plans for follow up, and the team had confirmed and agreed at the Melanoma MDT on 21 January 2020 to carry out the subsequent treatment surgery, Mr Sears was discharged from the Dermatology Department.13 Professor Brendan Coventry, who is a member of the RAH General Surgical Oncology team, has provided an affidavit. 14 Upon review of the medical records, he stated that the MDT recommendations do not appear to have been communicated back to the Surgical Oncology Clinic, which may have led to there being a lack of trigger for Mr Sears being booked in for review at the Surgical Oncology Clinic. Although the circumstances are somewhat unclear, it does appear that a communication breakdown occurred in respect of the next steps for Mr Sears and thus the plan for him to undergo a lymph node dissection and wide local excision was not actioned following the January MDT.

The SAPOL investigating officer observed in the report for the State Coroner there were challenges for the prison and medical officers involved in the treatment of Mr Sears.

Firstly, he was housed at a prison in Mount Gambier where the local medical officers thought he was too much of a risk to be treated locally. Secondly, his obesity made the transport between the prisons and hospitals more difficult. Thirdly, COVID-19 restrictions and his incarceration made face-to-face medical appointments challenging.15 However, it was not suggested that these factors explained the gap in treatment. Indeed, I observe that factors such as this are not unusual in the prison population, and it is within the capacity of the SAPHS to provide appropriate medical care in these circumstances.

12 Exhibit C13 at [10] 13 Exhibit C13 at [14] 14 Exhibit C14 15 Exhibit C9, page 21

[2025] SACC 16 State Coroner Whittle A SAPHS Critical Incident and Adverse Event Team Review16 concluded under the heading, ‘Were there any service or treatment gaps?’: ‘Possible missed opportunity for wide excision of melanoma and chemotherapy. Likely due to communication between RAH Dermatology and Surgical Oncology departments.

RAH have acknowledged this was suboptimal.’ As to whether Mr Sears’ death may have been prevented if the plan for resection was carried out following this January MDT, Dr Michael Brown, the chairperson of the MDT meeting on 21 January 2020, provided an affidavit17 confirming that, as at January 2020, Mr Sears had ‘potentially resectable’ clinical Stage III melanoma. He had no evidence of distant spread (beyond his left axilla) on a PET/CT scan and a CT chest/abdomen/pelvis scan done within the previous month. Molecular testing of the core needle biopsy of his left axillary lymph node confirmed that his melanoma bore a V600E BRAF mutation, which made him eligible for post-resection adjuvant medical therapy using dabrafenib and trametinib medications. This combination therapy had been listed on the PBS for this indication on 1 November 2019.18 Based on a published ‘Five-Year Analysis of Adjuvant Dabrafenib plus Trametinib in Stage III Melanoma’,19 Mr Sears had a 65% chance of distant metastasis free survival (for the intention-to-treat population).

Dr Brown concluded that based on that data, Mr Sears had a 35% chance of dying from metastases at five years after the putative start of adjuvant dabrafenib and trametinib therapy.20 Therefore, it was more likely than not that his death would have been prevented if he had completed the proposed treatment program, which included wide local excision of the incompletely-excised primary melanoma on his left upper arm and a left axillary nodal dissection.

Accordingly, I find that, had the recommendations from the MDT meeting in January 2020 been actioned shortly thereafter, Mr Sears’ death may have been prevented, or significantly delayed.

Conclusion I agree with the SAPOL investigating officer’s opinion that the circumstances surrounding the sudden death of James Frank Sears are not suspicious and do not indicate the involvement of any other person.

The standard of care provided by the RAH was unsatisfactory, particularly the failure to action the recommendation from the MDT meeting in January 2020. Actioning this recommendation would have significantly enhanced Mr Sears’ chance of an extended lifespan.

16 Exhibit C10 17 Exhibit C6 at [9] 18 Exhibit C6 at [14] 19 R Drummer et al. New England Journal of Medicine 2020; 383 (12): 11:39-11:47 20 Exhibit C6a at [5]

[2025] SACC 16 State Coroner Whittle Recommendations Professor Coventry expressed in his affidavit that he believed a clearer system needs to be developed which ensures: Recommendations following a RAH MDT are clearly recorded; 1.

The Clinical Summary of the MDT including the recommendations is sent 2.

to the referring clinician (whether internal or external); including copies to other relevant clinicians for any action(s); The general practitioner or primary care doctor (including the prison doctors) 3.

should be sent a copy of the summary, and it should be made clear that the recommendations are not didactic and binding, but advisory in nature (as is intended). The MDT summary needs to be clearly labelled in the main EMR (i.e. EPAS/ Sunrise or similar); The Clinical Summary is filed in the patient's clinical records in an easily 4.

locatable and known location, rather than only in the separate OACIS system; The MDT Chair needs to check that an appointment has been made (or is made) 5.

in the respective clinic for the next stage of management which would complete the chain of management better; and When a patient is 'listed' on an MDT for discussion, this needs to be followed 6.

up by the MDT Chair (and alerted on the EMR system) especially where details are incomplete or further actions are identified or required.21 To ensure a future similar communication breakdown resulting in an adverse outcome for a patient does not occur, I recommend to the Minister for Health and Wellbeing, the Chief Executive of SA Health and the Chief Executive of CALHN that MDT meeting processes be reviewed and a clear system be established for documenting, communicating, and following up upon Multi-Disciplinary Team recommendations. The review should not be confined to the Central Adelaide Local Health Network and should take into account the matters identified by Professor Coventry referred to above.

Keywords: Death in Custody; Prison; Hospital Treatment; Delay in Treatment 21 Exhibit C14 at [18]