Inquest into the death of Kumanjai Marshall

51y · Male·pneumonia secondary to hepatocellular carcinoma and chronic liver disease

A 51-year-old Aboriginal man died from pneumonia secondary to hepatocellular carcinoma and chronic liver disease while in custody. He had presented to hospital on 26 May 2010 with abdominal pain and imaging showed a large hepatic lesion suggestive of primary liver cancer. He repeatedly absconded from hospital before further investigations could be arranged. Upon incarceration on 24 August 2010, he presented unwell with abdominal tenderness. Subsequent MRI at Royal Darwin Hospital confirmed advanced multifocal hepatocellular carcinoma unsuitable for curative treatment. The coroner found that staff at both the correctional centre and hospital provided exemplary care and supervision. The clinical lesson centres on the aggressive nature of hepatocellular carcinoma in this case and the challenges posed by patient non-compliance with investigations in the community setting.