Inquest into the Death of Roy Charles GILBERT

49y · Male·Complications in Association with Advanced Gastric Malignancy

Roy Charles Gilbert, a 49-year-old prisoner serving an indefinite sentence, was diagnosed with advanced gastric adenocarcinoma in August 2013 after presenting with symptoms of constipation, weight loss, and vomiting. Gastroscopy revealed gastric outlet obstruction caused by metastatic disease. He underwent multiple interventions including stent placement and three cycles of chemotherapy, managed jointly by Royal Perth Hospital (oncology and gastroenterology) and prison medical services. Despite aggressive treatment, his cancer progressed with extensive peritoneal metastases. His compliance with treatment was inconsistent and his behaviour during hospital management was often uncooperative. He was escalated to palliative care in December 2013 and declared terminally ill (Phase 2). He died at Royal Perth Hospital on 21 December 2013 from complications of advanced gastric malignancy. The Deputy State Coroner found his supervision, treatment and care to be appropriate and reasonable given the aggressive nature of his cancer and his periods of non-compliance.