Coronial
WAother

Inquest into the Death of Allan Chapman

Deceased

Allan Chapman

Demographics

75y, male

Date of death

2004-04-04

Finding date

2005-03

Cause of death

Metastatic Lung Carcinoma

AI-generated summary

Allan Chapman, a 75-year-old sentenced prisoner, died of metastatic lung carcinoma on 4 April 2004 at Murdoch Community Hospice. He presented with lethargy and dysphonia in February 2004, leading to prompt chest imaging that revealed extensive lung cancer with liver metastasis. He was managed appropriately through Royal Perth Hospital's respiratory and palliative care services, with pain management optimised during hospice care. The coroner found his medical management was appropriate, with all reasonable treatment options explored by experienced physicians. The only issue identified was a procedural problem: the hospice had not been advised of Death in Custody procedures, resulting in the death scene not being sealed and family remaining with the body. The coroner recommended that community facilities accommodating sentenced prisoners be properly advised of Death in Custody procedures at the time they agree to provide care.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

palliative carerespiratory medicineoncologygeneral medicinecorrectional health

Error types

system

Clinical conditions

lung cancersmall cell carcinomametastatic cancerliver metastasisbone metastasisadrenal gland metastasis

Contributing factors

  • Small cell carcinoma, notoriously aggressive and resistant form of lung cancer
  • Liver metastasis
  • Bone metastasis
  • Adrenal gland metastasis

Coroner's recommendations

  1. Community facilities accommodating sentenced prisoners should be properly advised of Death in Custody procedures at the time they agree to provide care for sentenced prisoners
  2. Death in Custody procedures should be reinforced to ensure correct protocols are followed regardless of the physical location where the prisoner is accommodated
Full text

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