73y · Male·Metastatic colon cancer
… and anaemia, prompting hospital admission. Imaging revealed advanced colorectal cancer with hepatic and pulmonary metastases. Following multidisciplinary discussion involving oncology, palliative care, and family, a pa…
75y · Female·Pneumonia
…n. She presented with signs of aspiration pneumonia and was found to have advanced rectal carcinoma with pulmonary metastases on post-mortem imaging. The coroner found no evidence of deficient clinical management by eit…
56y · Female·sepsis secondary to disseminated pancreatic adenocarcinoma
… 2019 prompted appropriate escalation with imaging revealing advanced pancreatic cancer with hepatic and pulmonary metastases. The coroner found no deficiency in care; diagnosis timing was not unreasonable given the dia…
67y · Female·Complications of metastatic lung cancer, in a woman with chronic obstructive pul…
…s. In December 2022, she experienced functional decline, was admitted to hospital with hypoxia and brain metastases, developed possible seizure activity, and died six days later. The coroner found no preventable factors.…
72y · Male·Metastatic renal cell carcinoma
…static renal cell carcinoma, died in palliative care after admission on 29 April 2011. He had widespread metastases involving brain, bone, lungs, and adrenal glands at the time of death. The coroner found death resulted …
56y · Male·disseminated malignancy – known non-small cell carcinoma of lung
…ndings in 2011 and managed conservatively given his poor lung function. He progressed to brain and renal metastases by late 2015. The coroner found no deficiencies in supervision, treatment, or care. Mental health suppor…
48y · Male·Complications of metastatic melanoma
A 48-year-old man in custody at Port Phillip Prison died from complications of metastatic melanoma at St Vincent's Hospital. He had been diagnosed with melanoma in 2016 and developed metastatic disease in 2019. After pre…
78y · Male·large left basal ganglia intracerebral haemorrhage with mass effect
…nt Treatment Order (ITO) for acute hyperactive delirium. He had stage 4 lung cancer with extensive brain metastases discovered on MRI. His delirium was appropriately attributed to cancer rather than the initial fall. A m…
53y · Male·Complications of metastatic rectal cancer
Thomas Millar, a 53-year-old man in custody, died from complications of metastatic rectal cancer with liver failure. He had been diagnosed with advanced cancer in 2015 with a poor prognosis and underwent chemotherapy whi…
64y · Male·bronchopneumonia in a man receiving palliative care for terminal cancer of the r…
…ll Portelli, a 64-year-old man with chronic paranoid schizophrenia and terminal rectum cancer with liver metastases, died of bronchopneumonia (from aspirated vomit) while receiving palliative care at Alma Street Centre. …
53y · Male·metastatic carcinoma of the rectum (operated)
…st in custody and underwent surgery, chemotherapy, and radiotherapy. Despite initial treatment response, metastases developed in his lungs, liver, brain and spine. His care throughout his incarceration and final hospital…
72y · Male·inanition of terminal metastatic carcinoma of the left lung
…d lung disease from chronic smoking and was diagnosed with inoperable, aggressive lung cancer with brain metastases in early 2009. Palliative care with morphine was instituted. He deteriorated rapidly over the final mont…
71y · Female·Complications of metastatic intra-abdominal malignancy (unknown primary)
…bdominal malignancy of unknown primary. Initial assessment identified cancerous masses in the liver with metastases to lungs and bones. She received palliative care at home through Melbourne City Mission and DHHS staff, …
61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…
…ms. Lung lesions were identified on imaging in early April, with subsequent discovery of extensive liver metastases by May. The coroner found Mr May received regular, timely and appropriate medical care while incarcerate…
68y · Male·Metastatic gastro-oesophageal adenocarcinoma
…rgery due to poor ventricular function. CT imaging in April 2013 showed disease progression with hepatic metastases. He was transferred to St Vincent's Hospital in May 2013 and died shortly after. The OCSR and Justice He…
17y · Female·Metastatic Ewing sarcoma (palliated)
…te further chemotherapy, stem cell transplant and radiotherapy, she relapsed again in December 2020 with pulmonary metastases. At that point, care was appropriately shifted to palliative management with symptom-focused …
54y · Male·Complications of metastatic non-small cell lung carcinoma
…resentation, despite antibiotics and steroids, his condition deteriorated rapidly due to widespread lung metastases and organising pneumonia. Transition to palliative care was appropriate given disease progression. The a…
69y · Male·Metastatic non-small cell lung cancer on a background of dilated cardiomyopathy,…
Bruce Thomas, a 69-year-old man serving a custodial sentence, died of metastatic non-small cell lung cancer with concurrent dilated cardiomyopathy, COPD, and hypertension. Lung masses were discovered in May 2015 during a…
42y · Male·disseminated metastatic renal cell carcinoma
…etastatic disease to lungs was detected in March 2007, treated with Sunitinib until progression. Further metastases to brain and pericardium developed. The coroner found the initial diagnosis could not have been made ear…
63y · Male·disseminated carcinoma (pancreatic cancer with metastases to liver and lung)
George Papadopoulos, aged 63, died in prison custody from disseminated pancreatic carcinoma with metastases. He had refused imaging investigations due to unfounded concerns about radiation, despite recommendation…
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