Finding into death of Mr N
Deceased
Mr N
Demographics
62y, male
Date of death
2022-09-14
Finding date
2024-08-08
Cause of death
Metastatic small cell lung carcinoma (palliated)
AI-generated summary
Mr N, a 62-year-old man in custody, died from metastatic small cell lung carcinoma with palliation. He presented with abdominal pain in late May 2022, and was referred for urgent ultrasound and blood tests on 15 June 2022. However, the ultrasound was delayed due to unavailability of mobile ultrasound equipment, and subsequent follow-up was inconsistent with a period of one month without action. Despite these delays, the Coroners Prevention Unit and DJCS review concluded the medical care provided was reasonable and appropriate. Mr N was reviewed each time he reported symptoms and was referred to hospital for assessment when necessary. The coroner found no preventable factors and accepted that medical management was appropriate given the circumstances.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- delay in ultrasound investigation due to mobile ultrasound unavailability
- period of one month without follow-up action on ultrasound referral
- sepsis and multi-organ failure
- poorly controlled pain
- episodes of rapid atrial fibrillation
- unstable blood sugar levels
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