Findings into the death of Trevor Charles Stone

57y · Male·Metastatic lung adenocarcinoma (stage IVA non-small cell lung cancer)

Trevor Charles Stone, a 57-year-old First Nations man imprisoned for sexual offences, died from metastatic lung adenocarcinoma with contributing comorbidities (diabetes, hypertension, dyslipidaemia, ischaemic heart disease). Diagnosed with stage IVA non-small cell lung cancer in October 2019, he received appropriate oncological care including chemotherapy and immunotherapy (Nivolumab) at Princess Alexandra Hospital. Concerns were raised about delayed access to immunotherapy due to his incarcerated status and lack of Medicare eligibility; however, expert review confirmed treatment was of high professional standard and appropriately sequenced based on clinical need and biomarker profile. The coroner found no deficiencies in care, no suspicious circumstances, and that health services had adequate mechanisms for equitable medication access to Medicare-ineligible patients.