Inquest into the Death of Norman Alexander HAZELGROVE

73y · Male·metastatic carcinoma of the lung with palliation

Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed despite respiratory symptoms. The coroner identified missed opportunities for optimal follow-up during annual health assessments and blood pressure reviews over the subsequent years. However, she concluded this omission did not affect cancer development or outcome. After lung cancer diagnosis in May 2017, care was high-standard including appropriate palliative management. The key clinical lesson is the importance of formalising diagnoses and implementing systematic follow-up protocols, particularly for chronic respiratory disease in at-risk populations, even when immediate severity is not apparent. The coroner noted improved prison health screening processes were subsequently implemented.