59y · Male·metastatic lung cancer, with palliation
Van Tho Nguyen, a 59-year-old remand prisoner with metastatic lung cancer, died of natural causes in a private hospital palliative care setting. He had been a lifelong smoker…
56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…
Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer was appropriately inves…
66y · Male·metastatic oesophageal cancer
…016, was investigated at Royal Adelaide Hospital where CT and endoscopy confirmed advanced oesophageal adenocarcinoma with metastatic disease to lungs, liver, spleen and lymph nodes. Palliative care was agreed upon and h…
59y · Male·Disseminated carcinoma (metastatic adenocarcinoma of unknown primary origin)
Robert Theodore Stewart was a 59-year-old man with metastatic carcinoma of unknown primary origin who died in custody at Port Phillip Prison on 19 December 2013. He had been incarcerated since 2008 and diagnosed with dis…
76y · Male·Complications of metastatic renal cancer in a man with multiple medical co-morbi…
A 76-year-old man with metastatic renal cancer and multiple comorbidities died in prison from complications of his malignancy. Following a family meeting in November 2023, goals of care were clarified and the patient cho…
81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…
Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…
45y · Male·Complications of VATS procedure for locally advanced right upper lobe lung adeno…
A 45-year-old man died from complications following VATS lobectomy for lung adenocarcinoma. During initial surgery, the tumour invaded the T6 vertebral body. The surgeon, faced with i…
40y · Male·large bowel obstruction complicating disseminated carcinoma of rectum
…dy from large bowel obstruction complicating disseminated rectal carcinoma. He had been diagnosed with adenocarcinoma in 2004, treated with radiotherapy and chemotherapy, with progressive metastatic disease. In March 200…
56y · Male·Complications of advanced metastatic sigmoid adenocarcinoma in an adult man with…
Wayne Harris was a 56-year-old Aboriginal man with advanced metastatic sigmoid adenocarcinoma who died in prison custody from complications of his terminal cancer. He was incarcerated for 11 years…
67y · Female·disseminated adenocarcinoma of the colon
…ct others. Her health declined and the family consented to palliative care. She died from disseminated adenocarcinoma. The coroner found hospital care appropriate, with staff managing her complex medical and behavioural …
60y · Male·sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and m…
Henry Allen, a 60-year-old man with oral squamous cell carcinoma, lung cancer, and multiple comorbidities died from sepsis and aspiration pneumonia while in prison custody at Fio…
73y · Male·metastatic carcinoma of the lung with palliation
Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis…
75y · Male·metastatic pancreatic cancer
A 75-year-old man died from metastatic pancreatic cancer while in lawful custody. He was diagnosed in February 2025 and underwent palliative chemotherapy at Prince of Wales Hospital from March-April 2025. He developed an…
70y · Male·carcinoma of the lung
Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-rel…
62y · Male·extensive small cell lung cancer
Trevor John Smith, aged 62, died from extensive small cell lung cancer at Royal Adelaide Hospital on 18 March 2011. He was under Mental Health Act detention when he develo…
74y · Female·Metastatic duodenal carcinoma
…ith postural hypotension, fainting, and weakness. Investigation revealed metastatic duodenal carcinoma with lung and lymph node involvement, and chronic occlusive pulmonary emboli (off anticoagulation for two weeks). Ms …
58y · Male·Metastatic non-small cell lung carcinoma
Barry Haynes, a 58-year-old Aboriginal man, died of metastatic non-small cell lung carcinoma while on remand in custody. He had stage 4 lung cancer with brain metastases diagnosed in Novembe…
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