An 85-year-old man died in custody from cerebellar haemorrhage due to hypertension. He was in the palliative care unit following an advanced care directive refusing resuscitation. He reported nausea and vomited around 8pm; a doctor prescribed an antiemetic by telephone. He was found unresponsive at 10:45pm with no heartbeat. A post-mortem revealed acute intracranial haemorrhage in the left cerebellum with hydrocephalus. The coroner found no evidence of deficiency in care and treatment. This case highlights appropriate end-of-life planning and respect for advance directives in custodial settings.
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