Finding into death of Mr N

62y · Male·Metastatic small cell lung carcinoma (palliated)

Mr N, a 62-year-old man in custody, died from metastatic small cell lung carcinoma with palliation. He presented with abdominal pain in late May 2022, and was referred for urgent ultrasound and blood tests on 15 June 2022. However, the ultrasound was delayed due to unavailability of mobile ultrasound equipment, and subsequent follow-up was inconsistent with a period of one month without action. Despite these delays, the Coroners Prevention Unit and DJCS review concluded the medical care provided was reasonable and appropriate. Mr N was reviewed each time he reported symptoms and was referred to hospital for assessment when necessary. The coroner found no preventable factors and accepted that medical management was appropriate given the circumstances.