Si Ro Vo, a 61-year-old male imprisoned since April 2025, died from metastatic lung cancer with brain involvement while in palliative care at the prison inpatient unit. He had an Acute Resuscitation Plan documenting comfort care only, which was appropriately reviewed and updated in May 2025 to reflect comfort care for acute deterioration rather than escalation. Mr Vo became progressively unresponsive in his final week and was found deceased approximately 20 minutes after last observation. The death was expected in the context of terminal cancer and established palliative care pathway. No clinical errors or escalation failures were identified. The coroner found this to be a natural death in custody managed appropriately according to the patient's documented wishes and clinical condition.
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