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SAhospital2026-03-13

Coroner's Finding: Schlaefer, Norbert

69y · Male·disseminated urothelial carcinoma of the bladder (palliated), bilateral lung ade…

A 69-year-old man died in prison custody from disseminated urothelial carcinoma of the bladder, bilateral lung adenocarcinoma, and severe emphysema. He had a significant smoking history and prior asbestos exposure. His l…

oncologyrespiratory medicine
SAhospital2025-11-14

Coroner's Finding: Wallace, Peter John

67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …

Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…

hepatologyoncologyenoxaparin
SA2025-11-14

Coroner's Finding: Porter, Peter Raymond

65y · Male·metastatic prostate cancer complicated by deep vein thromboses

Peter Raymond Porter, aged 65, died in prison from metastatic prostate cancer complicated by deep vein thromboses in January 2022, eight and a half years after diagnosis. He had presented with urinary symptoms in Decembe…

oncologyurologyduodart
SA2025-08-28

Coroner's Finding: RJR

65y · Male·metastatic rectal cancer with extensive lung metastases

A 65-year-old man died from metastatic rectal cancer with extensive lung metastases while serving a prison sentence. He had presented with rectal bleeding symptoms since 2011 and returned a positive faecal occult blood t…

colorectal surgeryoncologyapixaban
SA2025-06-03

Coroner's Finding: Sears, James Frank

53y · Male·disseminated malignant melanoma

A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…

dermatologyoncologycommunicationsystemdabrafenib
SAhospital2025-05-20

Coroner's Finding: Foster, Stephen John

74y · Male·acute on chronic liver failure complicating common bile duct cholangiocarcinoma …

Stephen John Foster, aged 74, died in hospital from acute on chronic liver failure complicating common bile duct cholangiocarcinoma. He was serving a prison sentence at the time. Initial presentation with jaundice, eleva…

correctional healthsurgery
SA2024-09-13

Coroner's Finding: Mortess, Noel Allen

75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…

A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…

general medicinehaematologydelaysystemcefuroxime
SAhospital2024-09-13

Coroner's Finding: Zarrella, Dominic

88y · Male·aspiration pneumonia complicating vascular dementia and metastatic prostate canc…

An 88-year-old man with vascular dementia, metastatic prostate cancer, and chronic kidney disease died of aspiration pneumonia 15 days after admission to hospital under a Mental Health Act inpatient treatment order. He w…

oncologypsychiatry
SAhospital2024-01-19

Coroner's Finding: Le, Tu Loan

54y · Female·metastatic squamous cell carcinoma of the lung

Tu Loan Le, a 54-year-old woman on home detention release from prison, died from metastatic squamous cell carcinoma of the lung at The Queen Elizabeth Hospital on 9 May 2020. She had been diagnosed with stage 4 lung canc…

oncologypalliative care
SA2023-12-22

Coroner's Finding: Schuster, Gavin Shawn

45y · Male·Liver failure due to metastatic hepatocellular carcinoma

A 45-year-old male prisoner died from liver failure due to metastatic hepatocellular carcinoma. He had been prescribed cyproterone (Androcur) for 20+ years as an anti-libidinal agent, with regular blood tests monitoring …

psychiatryoncologycyproterone
SAhospital2023-04-28

Coroner's Finding: Adams, Geoffrey Gordon

72y · Male·cerebral malignancy (glioblastoma multiforme)

Geoffrey Adams, aged 72, died in custody from glioblastoma multiforme (cerebral malignancy). He presented with acute neurological symptoms (slurred speech, facial droop, weakness) on 13 November 2020 during a routine med…

neurosurgeryradiologywarfarin
SA2022-03-30

Coroner's Finding: Papadopoulos, George

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 recommendations for CT…

general practicecorrectional health
SAhospital2022-03-30

Coroner's Finding: Commisso, Salvatore

70y · Male·advanced left frontal glioblastoma (operated)

A 70-year-old male prisoner died from advanced left frontal glioblastoma. The tumour was identified when he presented with acute stroke-like symptoms (facial droop, weakness, confusion) in July 2018 while imprisoned. He …

neurosurgeryoncologyfluticasone/salmeterol
SAhospital2022-03-30

Coroner's Finding: Dunn, Julie Michele

56y · Female·sepsis secondary to disseminated pancreatic adenocarcinoma

Julie Michele Dunn, a 56-year-old female prisoner, died of sepsis secondary to disseminated pancreatic adenocarcinoma. She had presented months earlier with gastrointestinal symptoms (weight loss, nausea, vomiting, epiga…

general medicineoncologydiagnostictramadol
SA2021-01-15

Coroner's Finding: BALLARD Kenneth Frederick

75y · Male·cerebral metastatic malignancy (lung cancer with brain metastases)

Kenneth Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused…

general practicehaematologydiagnosticdelay
SA2021-01-15

Coroner's Finding: MITTIGA Saverio

89y · Male·multi-organ failure on a background of advanced dementia and small cell lung can…

An 89-year-old prisoner with advanced dementia and small cell lung cancer died from multi-organ failure whilst in lawful custody at Yatala Labour Prison. He entered prison aged 83 with complex medical needs including isc…

general practicepalliative caremorphine
SAhospital2020-12-18

Coroner's Finding: ANKER Paul Eugene

53y · Male·metastatic carcinoma of the rectum (operated)

Paul Eugene Anker, a 53-year-old prisoner, died from metastatic rectal carcinoma at the Queen Elizabeth Hospital. He had been appropriately diagnosed with bowel cancer in 2016 whilst in custody and underwent surgery, che…

oncologycolorectal surgerydexamethasone
SAhospital2020-11-02

Coroner's Finding: LAMB Dianne Patricia

67y · Female·disseminated adenocarcinoma of the colon

A 67-year-old woman with metastatic colorectal cancer developed multiple cerebral metastases causing marked behavioural changes (irritability, disinhibition, aggression). She was appropriately placed on Mental Health Act…

oncologypsychiatrydexamethasone
SA2020-10-12

Coroner's Finding: KEIRL Dennis Frank

63y · Male·metastatic carcinoma of the lung (small cell neuroendocrine carcinoma with poorl…

A 63-year-old male prisoner died from metastatic small cell lung cancer with adenocarcinoma features. Cancer was incidentally discovered during investigation of a deep vein thrombosis in October 2018, leading to one mont…

oncologygeneral medicinewarfarin
SAhospital2020-06-18

Coroner's Finding: BOYCE Ian Charles

85y · Male·hospital acquired pneumonia on a background of metastatic colorectal carcinoma

An 85-year-old man died from hospital-acquired pneumonia on a background of metastatic colorectal cancer. He was admitted to hospital with psychotic depression, suicidal ideation, and severe malnutrition after two years …

psychiatrygeriatric medicine

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