Coroner's Finding: Foster, Clive Anthony

76y · Male·end-stage renal failure

A 76-year-old man died of end-stage renal failure while imprisoned. He had pre-existing hypertension, diabetes, and stage 3 chronic kidney disease. During his final year in custody, he experienced acute kidney injury superimposed on chronic disease following gallstone-related illness, complicated by pneumonia, stroke, and cardiac dysfunction. He was assessed and deemed unsuitable for dialysis. The coroner found that adequate medical care was provided both in prison and hospital, with appropriate management of his complex medical conditions. The clinical lesson is that in elderly prisoners with advanced chronic kidney disease and multiple comorbidities, early identification of declining renal function and comprehensive palliative planning are essential. The prison health centre lacked appropriate end-of-life care resources, necessitating hospital readmission shortly before death.