Finding into death of XA

39y · Male·Complications arising from widely disseminated primary pulmonary small cell carcinoma

A 39-year-old male inmate died from complications of widely disseminated small cell lung cancer with hepatitis C cirrhosis. He presented with acute psychosis and catatonia in December 2018, receiving appropriate psychiatric care including ECT. During subsequent mental health admissions, he declined offers of hepatitis C investigation and treatment. The cancer presented atypically without classic signs until rapid decompensation with multi-organ failure on 21 February 2019. Autopsy revealed an extremely high-grade, aggressive tumour that had extensively infiltrated bone marrow and other organs. The Coroners Prevention Unit found no opportunities for earlier detection or prevention. All investigations during hospitalisations were appropriately conducted with normal results two months before death. The coroner accepted expert opinion that further invasive investigation would not have changed the outcome.