Coroner's Finding: Commisso, Salvatore

70y · Male·advanced left frontal glioblastoma (operated)

A 70-year-old male prisoner died from advanced left frontal glioblastoma. The tumour was identified when he presented with acute stroke-like symptoms (facial droop, weakness, confusion) in July 2018 while imprisoned. He underwent debulking surgery and received chemotherapy and radiotherapy as an outpatient. Despite appropriate palliative care coordination between prison health services and the Queen Elizabeth Hospital, his condition deteriorated progressively. He was transferred to palliative care in May 2019 and died in the palliative ward in July 2019. The coroner found no deficiencies in care. Clinically, this case illustrates the rapid progression of grade 4 glioblastoma and the challenges of early detection—such tumours rarely declare themselves clinically until advanced. The coordinated multidisciplinary approach to symptom management and end-of-life care was exemplary.