Coroner's Finding: GREEN David Vance
Deceased
David Vance Green
Demographics
42y, male
Date of death
2000-06-01
Finding date
2002-02-05
Cause of death
small cell lung cancer
AI-generated summary
A 42-year-old man imprisoned for rape died from small cell lung cancer at a hospice after a brief four-hour leave from prison. Cancer was detected within days of imprisonment when he presented with a persistent cough. He received appropriate chemotherapy and radiotherapy with poor prognosis recognised. Palliative care at the hospice was of appropriate standard. The case highlights a procedural issue: the death was not initially reported to the coroner because staff incorrectly assumed deaths outside prison walls during leave were not deaths in custody. The coroner found the death was not preventable and emphasised that correctional staff require clearer understanding that custody-related deaths extend beyond prison premises. Standard operating procedures required updating to reflect the broader legal definition of deaths in custody.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- aggressive malignancy
- poor prognosis at diagnosis
Coroner's recommendations
- Standard Operating Procedure 6 (SOP6) of Yatala Labour Prison should be revised to adequately reflect the legal position that deaths in custody extend beyond deaths occurring within prison walls, including deaths occurring while a prisoner is on authorised leave
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