Coroner's Finding: Adams, Geoffrey Gordon

72y · Male·cerebral malignancy (glioblastoma multiforme)

Geoffrey Adams, aged 72, died in custody from glioblastoma multiforme (cerebral malignancy). He presented with acute neurological symptoms (slurred speech, facial droop, weakness) on 13 November 2020 during a routine medical appointment in prison. Prison staff appropriately called an ambulance; CT imaging identified three intracerebral lesions. He was promptly transferred to Royal Adelaide Hospital where MRI and PET scanning were conducted to locate a primary cancer. Neuroradiologist review confirmed glioblastoma with very poor prognosis. The Coroner found his management in custody and at hospital was exemplary, with appropriate and timely assessment, transfer, and specialist involvement. No preventable factors were identified. Palliative care was provided until death on 15 December 2020.