Coronial
VIChospital

Finding into death of Mr N

Deceased

Mr N

Demographics

62y, male

Coroner

Coroner Sarah Gebert

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. Report an inaccuracy.

Specialties

oncologygeneral medicinepalliative care

Error types

delay

Clinical conditions

metastatic small cell lung carcinomasepsismulti-organ failureascitesliver metastasespulmonary emphysemapleural effusionsatrial fibrillation

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
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.