A Victorian prisoner killed himself after waiting three months for urgent medical treatment, a coroner has found.
Mladen Jovanoski, 57, died on April 11, 2018, after falling at Fulham Correctional Centre in the state's east.
In the three months leading up to his death, Jovanoski had treatment scheduled for suspected thyroid cancer but each of his three appointments were cancelled.
Coroner David Ryan, who this week released his findings into Jovanoski's death, determined medical staff were not consulted before each of the cancelled appointments.
Prison staff instead made the decision to cancel because there was no transport or staff available.
Jovanoski was anxious about the return of his thyroid cancer and the delay in medical treatment was causing him further anxiety and frustration, Mr Ryan said in his report.
A phone call with his lawyer on the morning of April 11, in which Jovanoski was heard arguing loudly, could also have acted as a trigger to his suicide, the coroner said.
Mr Ryan noted the medical staff at Fulham prison acted appropriately when the 57 year old threatened self-harm after his cancelled appointment on March 15.
Their general care for Jovanoski was of a high standard and reflected an admirable level of professional competence and empathy, the coroner said.
But the failure to facilitate timely medical treatment led to Jovanoski feeling hopeless and desperate, which motivated him to take his own life, Mr Ryan said.
"Mr Jovanoski was experiencing increased pain in his neck, was anxious to receive his treatment and was frustrated at the delay," Mr Ryan said in his findings.
"The seriousness of Mr Jovanoski's condition and the urgency of his treatment was not communicated to the right people."
Mr Ryan made six recommendations to Corrections Victoria, including to update its procedures so a health services manager is consulted before a medical appointment is cancelled.
The coroner also recommended a new policy requiring anyone involved in cancelling a medical transfer to record the circumstances, the reasons, and who was involved.
Mr Ryan's report noted Corrections Victoria Deputy Commissioner Melissa Westin has welcomed a number of recommendations.
Corrections Victoria has been contacted for comment.
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