Inquest into the death of Neal Richardson

48y · Male·large cell carcinoma of lung with metastases

Neal Richardson, a 48-year-old man serving a 28-year prison sentence, died of large cell carcinoma of lung with metastases while receiving palliative care at Prince of Wales Hospital. He had presented to prison health services in May-June 2014 with pain attributed to kidney stones. A CT scan on 27 April 2014 showed renal calculi; a subsequent CT on 23 June revealed rapidly progressive metastatic disease with liver, lung, adrenal, and bone involvement. The coroner found no clinical issues. The case highlights the importance of appropriate follow-up of incidental imaging findings and maintaining vigilance for alternative diagnoses in patients with persistent or worsening symptoms, particularly in custodial settings where medical oversight may be limited. Early recognition of metastatic disease could have allowed timely specialist assessment and palliative planning.