Inquest into the Death of Garth Cyril HEAVEN

57y · Male·Bronchopneumonia complicating metastatic and locally advanced primary adenocarcinoma of the right lung in a man under palliative care

A 57-year-old male prisoner died from bronchopneumonia complicating metastatic lung adenocarcinoma. He was diagnosed with stage IV lung cancer in February 2016 while incarcerated and opted for palliative care, declining chemotherapy. He received appropriate medical assessment across 98 prison medical visits, was properly transferred to hospital when pain management became inadequate, and was appropriately managed with palliative care at Bethesda Hospital. The coroner found supervision, treatment and care to be reasonable and appropriate throughout his incarceration. No clinical errors or preventable factors were identified. The death was from natural causes in the terminal phase of advanced cancer.