Coroner's Finding: OLIVER Ian Arthur

81y · Male·haemorrhage from metastatic squamous cell tumour of the right axilla

An 81-year-old man with extensive comorbidities (cardiac failure, COPD, diabetes, renal failure) presented with a right axillary squamous cell carcinoma with metastases. He was admitted for palliative care and pain management. On 21 February 2017, he became delirious and agitated, requiring an Inpatient Treatment Order. He developed a massive hemorrhage from the tumor on 26 February and died on 27 February 2017. The coroner found his detention was lawful and care was appropriate. No clinical errors or preventable factors were identified. The death resulted from natural causes—hemorrhage from metastatic malignancy in a palliative care setting.