Deceased
Lajos Szabo
Demographics
64y, male
Coroner
Deputy State Coroner Linton
Date of death
2019-02-03
Finding date
2021-08-06
Cause of death
metastatic adenocarcinoma of the lung (palliated)
AI-generated summary
Lajos Szabo, a 64-year-old prisoner, died from metastatic adenocarcinoma of the lung with brain metastases. He presented to prison medical services in November 2018 with neck swelling and fever, was promptly investigated, and diagnosed with advanced lung cancer by December 2018. The coroner found the standard of care was appropriate and equal to community standards. Key clinical lessons: (1) adenocarcinoma can present late with rapid progression; (2) secondary infection may complicate cancer presentation; (3) aggressive malignancies may progress despite treatment. The initial review was conducted by a nurse practitioner rather than a doctor, though the coroner noted this likely made no difference given the cancer's exceptional aggressiveness. A minor administrative issue was identified regarding non-initiation of Royal Prerogative of Mercy procedures when terminally ill status was declared, though this was not a clinical matter. The coroner commended the responsive care provided during his terminal decline.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
[2021] WACOR 25 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 27 JULY 2021 DELIVERED : 6 AUGUST 2021 FILE NO/S : CORC 152 of 2019
DECEASED : SZABO, LAJOS Catchwords: Nil Legislation: Nil Counsel Appearing: Sgt A Becker assisted the Coroner.
Mr L Geddes (SSO) appeared for the Department of Justice.
Case(s) referred to in decision(s): Nil
[2021] WACOR 25 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Lajos SZABO with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 27 July 2021, find that the identity of the deceased person was Lajos SZABO and that death occurred on 3 February 2019 at Bethesda Hospital, 25 Queenslea Drive, Claremont, from metastatic adenocarcinoma of the lung (palliated) in the following circumstances:
Lajos Szabo died at Bethesda Hospital on 3 February 2019. He had been diagnosed with terminal lung cancer and was receiving palliative care at the time he died, so his death was not unexpected.
Mr Szabo was a sentenced prisoner at the time of his death, serving a lengthy sentence imposed in December 2017. As Mr Szabo was a prisoner at the time of his death, he was a ‘person held in care’ under the terms of the Coroners Act 1996 (WA) and a coronial inquest into his death is, therefore, mandatory.1
I held an inquest on 27 July 2021. At the inquest, extensive written material was tendered in relation to the investigations into Mr Szabos’ death and, of particular relevance in this case, the medical care he received prior to his death. In addition, two witnesses from the Department of Justice were also called to give evidence at the inquest in person, to expand upon the information provided in the reports.
Mr Szabo was born in Hungary and reportedly had an unhappy childhood, marred by his mother’s alcoholism and a problematic relationship with his father. He completed two years of national service in Hungary and trained as an engineering fitter and baker.2 Mr Szabo was multilingual, being able to speak six languages, including English as a second language with limited ability to read and write in English3
Mr Szabo immigrated to Australia in 1980 when he was 26 years old. He met his wife in a migrant hostel in Sydney, where they were both living temporarily. They married and had their first daughter soon after. They had two daughters, and Mr Szabo’s wife was pregnant with their third daughter, when the family moved to Perth in 1989.4
Once in Perth, they rented a flat for a time in Maylands before moving to a house in Nollamara for the next decade. Mr Szabo’s wife worked as a nurse and he worked as a baker and bakery delivery driver. In his spare time, Mr Szabo’s main interest was restoring old motor vehicles and he also enjoyed fishing.5
Mr Szabo was said to have worked hard to provide for the family’s material needs but he was described as a domineering husband and abusive parent. He and his wife separated in 2006.6 Mr Szabo declared bankruptcy in 2009.7 1 Section 22(1)(a) Coroners Act.
2 Exhibit 1, Tab 2 and Tab 12.
3 Exhibit 2, Tab 1, p. 7 and Tab 12.
4 Exhibit 1, Tab 2 and Tab 12.
5 Exhibit 1, Tab 9 and Tab 12.
6 Exhibit 1, Tab 12.
7 Exhibit 1, Tab 12.
Mr Szabo began smoking cigarettes at the age of 13 years and he remained a heavy smoker for the rest of his life. He had no known chronic medical conditions and did not take any regular prescribed medication as an adult.8
Sadly, in 2016 Mr Szabo’s youngest daughter committed suicide.9 He was estranged from other daughters, due to his behaviour towards them in childhood and adulthood.
On 13 November 2017, Mr Szabo was convicted after a trial before a jury of 23 counts of sexual offending. The offences were historical and were representative of a prolonged course of conduct.10
On 6 December 2017 Mr Szabo was sentenced to a total effective sentence of 16 years’ imprisonment with eligibility for parole, backdated to commence on 13 November 2017 when he first went into custody. The learned sentencing Judge took into account the fact that Mr Szabo was 64 years of age at the time of sentencing. He was not known to have any health or medical problems that could not be adequately managed in prison.11
Mr Szabo’s sister later told police Mr Szabo had developed a lump at the nape of his neck four or five years prior to his death, so prior to his sentencing. He had apparently been informed by a doctor that if the lump grew, he would die, but he did not follow up with any treatments while living in the community.12
On his admission to prison on 13 November 2017, it was noted that Mr Szabo’s only supportive family member was his sister, who lived in Queensland. He was separated from his wife and both his two surviving daughters had been granted lifetime violence restraining orders against him.13 This was his first term of incarceration as a sentenced prisoner, having only previously spent two days in custody on remand.14
His only pre-existing medical conditions were reported as shoulder problems and a hernia. He also reported one self-harm attempt about three years prior, when he reportedly jumped in front of a bus, but denied any current suicidal ideation. Further, he indicated he was a long-term smoker and smoked more than a pouch of tobacco per week.15
After a week in Hakea Prison, Mr Szabo was transferred to Casuarina prison on 21 November 2017, where he was housed as a protection prisoner. He was transferred the next month to Acacia Prison, where he was said to be a quiet and polite prisoner who had limited interaction with other prisoners and largely kept to 8 Exhibit 1, Tab 2 and Tab 12.
9 Exhibit 1, Tab 12.
10 Exhibit 1, Tab 12.
11 Exhibit 1, Tab 12.
12 Exhibit 1, Tab 9.
13 Exhibit 1, Tab 2.
14 Exhibit 2, Tab 1.
15 Exhibit 2, Tab 1, p. 11.
[2021] WACOR 25 himself. He enrolled in adult learning and was also said to be a willing worker who completed tasks to a high standard with minimal supervision. Once a fortnight he spoke to his sister on the telephone. He had no contact with any other family or friends.16
On 27 March 2018 Mr Szabo had his first health review in prison. I note he was supposed to have been booked in for review with a doctor on admission in November 2017, but the appointments kept getting cancelled when he moved prisons. Nursing appointments in January, February and March 2018 were also cancelled as Mr Szabo did not attend, so his first full review by a doctor or nurse after his initial nurse admission review was on 27 March 2018. He did not actually have an appointment with a doctor until November 2018, although a doctor was involved in reviewing his pathology results in the interim.
When he was reviewed in March 2018 at Acacia Prison, the review was conducted by a nurse practitioner. A nurse practitioner has an extra two years training on top of a nursing degree, which permits them to prescribe a very wide range of medications and order a further range of tests than a nurse. Nurse practitioners are required to by supervised by a medical practitioner, which is the case at Acacia Prison.17
At this review, Mr Szabo reported no health concerns and said his mood was good.
He underwent a comprehensive assessment and was given education on smoking, nutrition, alcohol and physical activity. A plan was made for Mr Szabo to have some blood tests and then a follow-up review. He underwent a series of blood tests on 11 April 2018, which were all normal. A doctor reviewed the results and confirmed there was no need to arrange follow-up for Mr Szabo at that time.18
In May 2018 Mr Szabo applied for an interstate transfer to Queensland, where his sister resided. The application was supported by the Department, but it did not eventuate as the approval process can take up to 12 months to complete and he became very unwell before it was finalised. Mr Szabo did continue to have regular contact with his sister by letter and over the telephone, and also via Skype.19
On 12 July 2018, Mr Szabo was administered the annual influenza vaccine.20
Strangely, on 11 November 2018 a nurse made an entry that Mr Szabo did not require an annual health assessment as he had “been reviewed regularly by medical.” Given he had still not been reviewed by a doctor at this stage, it’s unclear whether this was an error. In any event, he saw a doctor 11 days later after he presented for review to a nurse reporting a painful lump in his neck, so it was not significant in the context of Mr Szabo’s care.21 16 Exhibit 1, Tab 2, Tab 17 and Tab 18; Exhibit 2, Tab 1.
18 Exhibit 2, Tab 23, pp. 3 – 4.
19 Exhibit 2, Tab 1, pp. 9 - 10.
20 Exhibit 2, Tab 23.
21 Exhibit 2, Tab 23, p. 4.
He was reviewed by a nurse and he then returned the following day, where the right side of the neck was seen to have increased in size since the previous day. He was seen by a doctor on 22 November 2018, who noted a raised temperature of 38˚C and an obvious swelling to the right side of his neck. Mr Szabo reported he had been experiencing pain in his neck for four days and swelling for two days. The diagnosis was unclear at the time, but infection was suspected. He was commenced on antibiotics and given pain medication while urgent blood tests and mumps serology were requested.22
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. He still had a high temperature and the doctor found there was still swelling on examination.23
Mr Szabo’s blood test results came back on 27 November 2018 and were very abnormal. A plan was made for further review by a doctor and the blood pathology tests were to be repeated.24
Mr Szabo saw the nurse the next day for further blood samples to be taken and he reported feeling some improvement on antibiotics and his temperature was normal.
However, the repeat blood tests on 28 November 2018 showed worsening liver function, ongoing anaemia and persistently raised CRP, white cell count and platelets.25
On 29 November 2018, Mr Szabo was reviewed by the doctor again who noted there was still soft swelling to the right side of the neck and very high inflammatory markers in what appeared otherwise to be a well man. The doctor suggested further blood tests be taken, with medical review 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.26
On 7 December 2018, before Mr Szabo was reviewed again by a prison medical officer, a code blue occurred as Mr Szabo complained of acute chest pain and shortness of breath. An ECG was conducted. He was reviewed by a doctor, who noted his recent bloods were still abnormal with indication of infection and it was decided he should be sent to St John of God Hospital Midland by ambulance for urgent medical review.27 22 Exhibit 2, Tab 23, p. 5.
23 Exhibit 2, Tab 23, p. 6.
24 Exhibit 2, Tab 23, p. 6.
25 Exhibit 2, Tab 23, p. 6.
26 Exhibit 2, Tab 23, p. 6.
27 Exhibit 2, Tab 1, p. 4; Exhibit 2, Tab 23, p. 7.
Mr Szabo was admitted to St John of God Hospital Midland that day. He reported pleuritic type chest pain with shortness of breath and dizziness. His recent history of a lump in his neck was noted and he also stated he had a chronic cough with brown sputum.28
Mr Szabo underwent a CTPA (CT pulmonary angiogram) 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. His antibiotics were changed and a lymph node biopsy was performed on 10 December 2018. During the procedure it was noted that he had a jugular vein thrombosis, most likely due to pressure from the neck mass, so he was commenced on an anticoagulant.29
Mr Szabo was discharged back to prison on 11 December 2018 with an appointment to see his specialist Dr Manners, a Respiratory Physician at SJOG Midland, in the outpatient clinic in a week. Mr Szabo was reviewed by a prison doctor on his return to prison that day and he indicated he was not in pain and wanted to go back to his cell. He remained on pain relief and oral antibiotics, which were administered by a nurse daily.30
Dr Manners reviewed Mr Szabo on 13 December 2018 and informed him the biopsies confirmed non-small cell lung cancer (adenocarcinoma). On his return to prison that day, Mr Szabo was spoken to by a nurse and offered prison counselling services for support, but he declined.31
He was reviewed by the Radiation Oncologist at Sir Charles Gairdner Hospital on 14 December 2018 and a course of radiotherapy was commenced on 17 December
Mr Szabo was registered on the Department’s terminally ill register on 27 December 2018.32
29 Exhibit 2, Tab 23, p. 7.
30 Exhibit 2, Tab 23, p. 8.
31 Exhibit 2, Tab 23, p. 8.
32 Exhibit 2, Tab 1, p. 5.
33 Exhibit 2, Tab 23, p. 10.
Mr Szabo was discharged back to prison on 3 January 2019 and, at his request, his radiotherapy was postponed for several days. He indicated he was considering stopping the radiotherapy due to the associated oedema.34
Mr Szabo was noted to be unable to walk on 5 January 2019 due to swelling of his lower legs. He was brought into the medical centre via internal ambulance and had to be helped into a wheelchair and then into bed. A nurse conducted an ‘e-consult’ with the on call doctor and it was decided he should remain in the medical centre overnight for observation.35
His condition deteriorated overnight and he was noted to be unable to control his bladder. On 6 January 2019 Mr Szabo was transported to SJOGH Midland Emergency Department, where he was diagnosed with a urinary tract infection. He was commenced on antibiotics and transferred back to prison.36
By 8 January 2019 Mr Szabo had declined to the stage that he could no longer walk and required a wheelchair. He was transferred to the Casuarina Prison Infirmary, where he could receive better medical care. He was provided with a walking frame and encouraged to use it to stand when possible, to reduce leg swelling.37
On 9 January 2019, Mr Szabo reported he was happy to continue with radiotherapy.
He was suffering from constipation, so he was prescribed regular aperients.38
Mr Szabo was reviewed by the Medical Oncologist at SCGH on 11 January 2019, who felt Mr Szabo was not suitable for chemotherapy.
Mr Szabo’s condition continued to deteriorate over the next few days, with weight loss, increasing weakness and difficulties mobilising. He completed his course of radiotherapy on 14 January 2019; however, a PET scan done the same day showed the cancer had spread to his brain.39
From 15 January 2019, Mr Szabo had a carer allocated to attend to his daily living needs as his ability to self-care was declining.40
On 17 January 2019 Mr Szabo was reviewed by the Metropolitan Palliative Care Consultancy Service. He was noted to be very fatigued, bedbound, weak and experiencing nausea and urinary incontinence. They recommended palliative care at Bethesda Hospital, once a bed became available.41 34 Exhibit 2, Tab 23, p. 11.
35 Exhibit 2, Tab 23, pp. 12 - 13.
36 Exhibit 2, Tab 23, p. 13.
37 Exhibit 2, Tab 1, pp. 10, 13.
38 Exhibit 2, Tab 23, p. 14.
39 Exhibit 2, Tab 23, p. 15.
40 Exhibit 2, Tab 23, p. 15.
41 Exhibit 2, Tab 23, pp. 15 – 16.
He reported he was ready to die and did not want any life prolonging treatment.
Records indicate his sister flew to Perth and was able to visit him and say goodbye on 29 January 2019.42
Mr Szabo was kept comfortable until he passed away on the morning of 3 February 2019.43
Police officers attended the hospital as part of commencing a coronial investigation into the death. Nothing of concern was identified.
Microscopic examination of tissue showed adenocarcinoma and pneumonia in the right lung and a metastatic tumour in the mediastinal lymph nodes.44
Neuropathological examination of the brain showed multiple metastatic tumours.45
Toxicological analysis showed the presence of medicines consistent with Mr Szabo’s palliation regime.46
At the conclusion of all investigations, Dr McCreath formed the opinion the cause of death was metastatic adenocarcinoma of the lung (palliated). I accept and adopt Dr McCreath’s opinion as to the cause of death. It follows that the death occurred by way of natural causes.
43 Exhibit 1, Tab 10.
44 Exhibit 1, Tab 6.
45 Exhibit 1, Tab 7.
46 Exhibit 1, Tab 8.
[2021] WACOR 25 was far more likely to be a residual lymph node from an old cold or an old tonsilitis.47
While in prison, he does not appear to have shown any symptoms of lung cancer, or sought any help for health complaints, until he presented with a complaint of a lump in his neck in November 2018. Appropriate investigations were immediately undertaken, and Mr Szabo was quickly diagnosed with metastatic lung cancer.
Dr Rowland was asked whether there was any possibility that an earlier medical review might have detected the cancer. Dr Rowland indicated that doctors who have done GP training and are specialist general practitioners do follow guidelines on preventative health screening intended to promote the detection of subtle signs and symptoms and promote age-related screening. The nurse practitioner’s template would have been similar, but it is possible that the additional experience of a doctor may have assisted in looking for any subtle signs. The earlier cancer is detected, the greater the person’s survival chances, so any earlier detection would be important.
However, there is nothing in particular to suggest that there were early signs that were missed, only perhaps a missed opportunity for a more focussed discussion with Mr Szabo if a doctor had been involved. Information was provided that adenocarcinoma of the lung can present late in the course of the disease and progress rapidly.48
Dr Rowland gave evidence that it is possible he did have a secondary infection in the same area where the cancer had developed, as he had a red sore lump and markers of infection in his blood and he responded to antibiotics. Dr Rowland indicated that it is not unusual for a cancer diagnosis to be incidental to another issue. In this case, once it became apparent that his abnormal blood results were still abnormal, and he was still showing concerning signs, he was sent by ambulance to hospital and further investigations diagnosed the cancer quickly.
By the time it was detected, there was little that could be done. Dr Rowland explained that the cancer had started in his lung and then metastasised and spread into his lymph nodes in his neck. It was very aggressive and was growing exponentially. At the time of his diagnosis, the cancer had already progressed to a stage where curative treatment was not possible. He was given palliative radiotherapy in an effort to shrink the tumours. He was not felt suitable for chemotherapy.49 Dr Rowland gave evidence the short delay before the first medical review in Acacia Prison and the diagnosing of the cancer in hospital was not unreasonable in the circumstances, and “given the aggressiveness of his cancer it’s very unlikely 17 days would have altered his final outcome.”50
Despite the radiotherapy treatment, Mr Szabo’s cancer quickly progressed, and several weeks after his diagnosis the cancer had spread to his brain. Mr Szabo’s
48 Exhibit 2, Tab 23, p. 17.
49 Exhibit 2, Tab 23.
[2021] WACOR 25 cancer’s progress was described as unusually rapid.51 His prognosis was very poor.
He became increasingly frail, weak and incontinent, and was appropriately transferred to Bethesda Hospital, where he could receive palliative care so that he could end his days in relative comfort.
Once his lung cancer was diagnosed, the standard of care was consistent with what he could have expected in the community. It was identified in the Department’s ‘Death in Custody Review’ that Mr Szabo’s prison medical notes did not reflect any potential counselling or advice related to encouraging him to cease smoking, although it may have been done and not documented.52 In the health services summary provided by the Department, I note there is an entry from a nurse practitioner who reviewed Mr Szabo on 27 March 2018, where they discussed his smoking and it is indicated he was given education regarding smoking, amongst other things.53 Further, I note he was a long-term smoker, and was apparently aware of the lump in his neck prior to his imprisonment and had taken no steps to cease smoking, so he was not going to be persuaded to stop. Medical staff have also since been reminded to document in the EcHO notes when counselling prisoners about ceasing smoking, so that there is a clear record that it has occurred.54
Information was provided that Mr Szabo was transferred to hospital on 19 occasions between 7 December 2018 and 14 January 2019. After he raised with a nurse how difficult he was finding it in the transport van, approval was sought and given for his transfers to be undertaken in a soft seat unsecure vehicle without shackles to his legs to make him more comfortable, which indicates the Department’s staff were alert to his needs and did their best to ease his journey on these occasions.55
It was identified in the Department’s ‘Death in Custody Review’ that procedures concerning the potential exercise of the Royal Prerogative of Mercy were not initiated when Mr Szabo was listed as terminally ill (Stage 3) or updated when he was listed as Stage 4 terminally ill, as required by the Department’s Policy Directive 8 relating to Prisoners with a Terminal Medical Condition. It was noted in the review that the likelihood that the Department would recommend Mr Szabo’s early release was low considering his offending and the length of his term of imprisonment still to serve. It was also noted that the exercise of the RPOM is a Ministerial prerogative even if the Department made a recommendation. Nevertheless, it was acknowledged on behalf of the Department that the Minister for Corrective Services should have been notified of Mr Szabo’s terminal status so that this issue could be considered.56
Ms Toni Palmer, a Senior Review Officer for the Department, recommended that the requirements of Policy Directive 8 be reinforced to the relevant staff responsible and it was noted that the Sentence Management Unit has been provided with an additional position, with the task of the provision of Terminally Ill briefings being undertaken by the person in that role. Ms Palmer gave evidence that last year, at the
52 Exhibit 2, Tab 1, p. 6.
53 Exhibit 2, Tab 23, p. 4.
54 Exhibit 2, Tab 1, pp. 16 - 17.
55 Exhibit 2, Tab 1, p. 12.
56 T 6; Exhibit 2, Tab 1, pp. 6, 15.
[2021] WACOR 25 height of COVID, the Department did a blanket review of everybody that was terminally ill from stages 1 to 4 (which is outside the usual policy) but as a result of that review, no prisoner was released on the RPOM. This ensured that there was no backlog of prisoners who had not gone through the process. Since that time, the new staff member in Sentence Management Unit has commenced and is in charge of ensuring there is compliance with the policy.57
S H Linton Deputy State Coroner 6 August 2021 57 T 6 – 7; Exhibit 2, Tab 1, p. 15.
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