Coroner's Finding: SMITH Trevor John

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 developed delusions and delirium during his final illness. The coroner found no clinical errors contributed to his death; the delusions appeared related to his advanced malignancy rather than medication. However, a significant administrative failure occurred: hospital staff did not report his death to the coroner until three days after his death despite his detention status requiring mandatory reporting. This delay caused substantial distress and financial hardship to his family who had arranged funeral services based on incorrect information. The case highlights the importance of ensuring all hospital staff understand their legal obligations regarding timely coroner notification of deaths in custody.