Inquest into the death of Shane Anthony May

61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspicious of bronchogenic carcinoma left lung)

Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory and abdominal symptoms. Lung lesions were identified on imaging in early April, with subsequent discovery of extensive liver metastases by May. The coroner found Mr May received regular, timely and appropriate medical care while incarcerated, with no clinical delays that would have altered outcome. A forensic pathologist confirmed that even earlier diagnosis would not have changed prognosis given the aggressive nature of metastatic disease. Care was appropriately transitioned to palliative management based on his wishes and in consultation with family. No clinical errors or preventable factors were identified.