Inquest into the Death of Herbert William MACKAY

45y · Male·complications associated with metastatic adenocarcinoma of the lung, treated palliatively

Herbert Mackay, a 45-year-old Aboriginal man, died from complications of metastatic adenocarcinoma of the lung discovered at stage 4 in late December 2020 while imprisoned at Casuarina Prison. He presented with respiratory symptoms on 31 December 2020 and underwent five hospital admissions over three months for management of recurrent pleural and pericardial effusions requiring drainage procedures. The coroner found the lung cancer presented at an advanced stage with diffuse cell growth unlikely detectable earlier by imaging, and that medical investigations were promptly commenced and appropriately managed. Clinical care in prison and hospital was found to be fair, reasonable and appropriate. The coroner identified opportunities for improvement in communication between prison and hospital regarding discharge care capabilities, and endorsed the prison system's smoke-free initiative, though there was no evidence smoking directly caused his cancer.