Inquest into the death of Bundy Namarnyilk

56y · Male·Acute bronchopneumonia secondary to locally advanced, poorly differentiated squamous cell carcinoma within the right side of the neck

A 56-year-old Aboriginal man died in custody from bronchopneumonia secondary to metastatic hypopharyngeal squamous cell carcinoma. He first presented with sore throat in February 2014 and was referred to ENT clinic in April 2014, diagnosed May 2014. Despite aggressive surgery and radiotherapy, his cancer progressed rapidly with residual disease involving vital neck vessels. He deteriorated over months and transitioned to palliative care in December 2014. The coroner found his initial management at the prison clinic was appropriate, with timely specialist referral and exemplary investigations. Earlier referral would not have changed outcomes given the aggressive tumour type which typically presents at advanced stage. No failures in medical care were identified. The custodial decisions regarding overnight family visits and temporary release were found reasonable and in accordance with directives.