Deceased
Mustafa Kayirici
Demographics
31y, male
Coroner
Decision ofDeputy State Coroner Forbes
Date of death
2022-01-25
Finding date
2026-03-10
Cause of death
metastatic alveolar soft part sarcoma
AI-generated summary
31-year-old man serving a custodial sentence died of metastatic alveolar soft part sarcoma on 25 January 2022. Diagnosed April 2020, the ultra-rare cancer (1 in 10 million incidence) had already metastasised at discovery. Early symptoms of coughing blood in January 2020 were not evaluated by a GP until April 2020 (three months delay), though expert opinion concluded earlier diagnosis would not have altered outcome as disease was advanced. Patient-initiated pain complaints from 2010-2012 concerning left hip/back pain were unrelated to sarcoma; attempted MRI investigations were repeatedly cancelled but expert confirmed spinal pathology explained symptoms. After diagnosis, cancer management was best practice with advanced therapeutics including compassionate-access Cediranib. End-of-life planning involved appropriate palliative care discussions though patient and clinicians disagreed on resuscitation status, with team view prevailing. Death from natural causes while in lawful custody.
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CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Mustafa Kayirici Hearing dates: 9-10 February 2026 Date of findings: 10 March 2026 Place of findings: Coroners Court of New South Wales, Lidcombe Findings of: Magistrate Carmel Forbes, Deputy State Coroner Catchwords: CORONIAL LAW – mandatory inquest – death in custody – cause of death – medical care and treatment – end of life planning and care File number: 2022/0023460 Representation: Counsel Assisting the inquest: J Harris of Counsel instructed by Solicitor, Coroners Court Secondment Unit Commissioner of Corrective Services NSW: J de Castro Lopo, Department of Communities and Justice Legal Chief Executive of the Justice Health and Forensic Mental Health Network: B Bradley of Counsel instructed by Hicksons Mustafa Kayirici’s family: E McLaughlin of Counsel instructed by Legal Aid NSW Non publication orders Non-publication orders made on 24 July 2025 and 22 December 2025.
A copy of the orders can be obtained on application to the Coroners Court of New South Wales registry.
Findings: Identity of deceased: The person who died was Mustafa Kayirici.
Date of death: Mustafa died on 25 January 2022.
Place of death: Mustafa died at the Prince of Wales Hospital, Randwick,
Manner of death: Mustafa died from alveolar soft part sarcoma.
Cause of death: Mustafa died as a result of natural causes while he was in lawful custody.
Recommendations: Nil.
REASONS FOR DECISION Introduction
Mustafa Kayirici was a 31-year-old man who died of metastatic alveolar soft part sarcoma on 25 January 2022 while he was serving a custodial sentence. At the opening of the inquest Mr Kayrici’s family asked that he be referred to as Mustafa. For this reason, throughout these findings, I will refer to him by that name.
An inquest is required to be held into Mustafa’s death, because he died while he was serving a sentence in custody.1
The role of a coroner as set out in s 81 of the Coroner’s Act 2009 (NSW) is to make findings as to: i. the identity of the deceased; ii. the date and place of the person’s death; iii. the physical or medical cause of death; and iv. the manner of death, in other words, the circumstances surrounding the death.
Section 82 of the Coroner’s Act 2009 (NSW) provides that a coroner may consider whether it is necessary or desirable to make recommendations about any matter connected with the death. This includes matters of public health and safety.
This inquest has been a close examination of the medical care and treatment Mustafa received while he was in custody and pursuant to section 37 of the Coroner’s Act 2009 (NSW), a summary of the details of this case will be reported to Parliament.
The Evidence
independent expert reviews of Mustafa’s diagnosis and medical treatment while in custody.
Background
At the family’s request I will only set out Mustafa’s background as far as it is relevant to the issues of this inquest.
Other than brief periods in the community in 2010, 2011, 2014 and 2016, Mustafa spent most of his adult life in custody. On 26 June 2016 he was arrested and remained in custody until his death in 2022.
Mustafa had a brain injury, which he had sustained in a bike accident when he was about
He also had mental health and personality issues, including borderline personality disorder, schizophrenia, anxiety and obsessive compulsive disorder (OCD).
Alveola soft part sarcoma (ASPS)
Dr Andelkovic informed the Court that ASPS is a malignant tumour of soft tissue. It is ultra rare with an incidence of one in ten million2. Dr Kertesz informed the Court that it predominantly affects young people and has a high incidence of metastatic disease at diagnosis3.
On 14 January 2020, Mustafa reported that he had a cough and was spitting up blood.
On 21 January 2020, he completed a Patient Self-Referral form asking for his chest to be examined.
Dr Andelkovic is of the opinion that these were the first records of symptoms which are related to Mustafa’s ASPS.
On 27 January 2020, Mustafa was reviewed by a nurse. He told them that 3 days prior he had a bad cough, and his sputum was stained with blood. His vital signs were taken, 2 Exhibit 1 Volume 28 Tab 99 p 10377 3 Exhibit 1 Volume 28 Tab 97 p 10310
which were between the flags, and he appeared otherwise well, with clear chest sounds and no signs or symptoms of respiratory infection.4
The following day, Mustafa punched a wall and fractured a bone in his hand; he was taken to Long Bay hospital for review.5
On 28 January 2020, Mustafa was placed on a waitlist for review, because he had a large lump on his shoulder blade and said he had been coughing up blood every few months.
He was seen by the nurse manager on 17 April 2020, and raised a number of complaints, including a lump in his left thigh.
On 23 April 2020, Associate Professor John Dearin (Justice Health) reviewed Mustafa at the prison clinic. He found an ovoid lump in the front side of the left thigh, about 14cm in diameter. Dr Dearin referred Mustafa for an ultrasound.6
On 28 April 2020, Mustafa underwent a CT scan on his thigh. This showed a large highly vascular mass, suspicious for sarcoma. An MRI was recommended.7 It was performed on 15 May 2020.8 A biopsy of the thigh mass confirmed it was ASPS.9
A PET scan was also performed on 11 May 2020. It revealed possible metastases in the inguinal lymph nodes, and a confirmed secondary tumour in the right lower lobe of the lung.10 A CT brain scan taken on 25 May 2020 did not reveal any evidence of metastases in the brain.11
Initially, Mustafa was under the care of doctors at Prince of Wales Hospital (POWH), including Dr Yeh Chen Lee. They recommended he commence chemotherapy, and if that was not successful, to move to a second-line drug called Pazopanib. This drug was available in Australia if chemotherapy was not successful. However, Mustafa was concerned about his fertility, and he did not want to start chemotherapy.
4 Exhibit 1 Volume 13 Tab 66 p 5005 5 Exhibit 1 Volume 13 Tab 66 p 5007 6 Exhibit 1 Volume 14 Tab 66 p 5061 7 Exhibit 1 Volume 11 Tab 66 p 3855 8 Exhibit 1 Volume 11 Tab 66 p 3866 9 Exhibit 1 Volume 11 Tab 66 p 3888 10 Exhibit 1 Volume 11 Tab 66 p 4172 11 Exhibit 1 Volume 11 Tab 66 p 3874
He was engaged with the palliative care team in about July 2020. He was later engaged with an oncology dietician and physiotherapist.
Mustafa wanted a second opinion on his treatment. On 2 July 2020, he saw Dr Vivek Bhadri, a medical oncologist at Chris O’Brien Lifehouse. Dr Bhadri explained to Mustafa that his metastatic disease was not curable with surgery. He also informed Mustafa that he would eventually die from the disease, but his prognosis was uncertain, and could be many years, depending on his response to treatment. Dr Bhadri recommended treating Mustafa with Pazopanib, or a separate drug, Cediranib, which was only available through compassionate access from the manufacturer, AstraZeneca, in the UK.
In September 2020, Mustafa was reviewed by Associate Professor Smee, at POWH, in relation to radiotherapy for the tumour in his lung.
On 6 November 2020, Mustafa was approved to commence Pazopanib, and he commenced that drug on 18 November 2020.
On 9 December 2020, Mustafa suffered a stroke. He had a CT brain scan which did not identify metastases in his brain. He declined to have an MRI.
By April 2021, brain metastases were identified. These had developed despite his treatment with Pazopanib.12
In August 2021, Dr Bhadri sought compassionate access to Cediranib. That was approved and he commenced this drug on 18 October 2021.
On 12 January 2022, Mustafa was taken for an appointment at POWH to have a CT scan.
This identified an increase in the size of brain lesions and progression of his metastatic since the previous scans.
12 Exhibit 1 Volume 11 Tab 66 p 4005
He was admitted under the care of Dr Melvin Chin (Medical Oncologist, POWH). He was agitated and had a reduced level of consciousness. After investigations it was considered that his advancing disease was the cause of his symptoms.
The treating team consulted Dr Bhadri and the palliative care team about treatment. It was determined to treat his symptoms and make him comfortable. A resuscitation plan was prepared, stating that Mustafa would not have CPR, reflecting an existing resuscitation plan.13
His condition deteriorated over the next week, and by 19 January 2022 he was able to open his eyes but was not speaking or following commands.
He was provided morphine, midazolam and levomepromazine.
On 25 January 2022, he was attended by nursing staff throughout the morning and at 10.25am he was declared deceased.
Autopsy
(a) When did Mustafa develop ASPS?
front of Mustafa’s thigh deep in the tissue and that Mustafa did not notice the lump prior to noticing the metastatic disease, namely the secondary tumour in his lung.
(b) Was there an MRI scan in 2011 that showed a mass in Mustafa’s left hip?
On 15 May 2020, Associate Professor Robert Smee at POWH wrote a letter regarding a biopsy which was taken of Mustafa’s tumour. In that letter he made the following comment: “Interestingly the patient had an MR of the left hip in 2011, and that mass was apparent at that time.”14
Associate Professor Smee made a similar comment in a second letter, on 14 September 2020, where he stated: “Interestingly imaging available from a few years prior to this year document the likely presence of that mass, be it smaller.”15
Despite extensive searches and enquiries, that MRI has never been located.
There is no contemporaneous record of an MRI in 2011, there is no report, image, or any reference to an MRI in any hospital or Justice Health notes between 2010 and 2016.
Associate Professor Smee gave evidence during this inquest that he was provided with the information about the 2011 MRI in the course of a sarcoma multidisciplinary (MDT) meeting at POWH. He never saw the MRI. He does not now recall who provided the information, or any further details. Associate Professor Smee says he only reviewed Mustafa on one occasion, in September 2020, and he is of the opinion that the person who gave him the information about an MRI must have made a mistake.
14 Exhibit 1 Volume 11 Tab 66 p 3888 15 Exhibit 1 Volume 11 Tab 66 p 3921
(c) Was the back, buttock and left hip pain Mustafa reported to Justice Health related to his ASPS?
From early 2010, Mustafa complained of back and left leg pain. He was reviewed by Dr Jacques Ette (Justice Health) on 8 January 2010.16 Among other things, Mustafa complained of left hip pain on external rotation. He was referred for an X-ray of the pelvis and left hip. That was performed on 21 January 2010 and did not detect any abnormality.17
He was reviewed by Dr Baguley (Justice Health) on 13 April 2010. The doctor noted some pain in the left hip and at extremes of movement, but that Mustafa was walking and the X-ray was normal.18 He was released from custody 2 weeks later.19
Mustafa attended a doctor while he was in the community at Auburn and raised the same issue.
When he returned to custody in October 2010, he again complained of left hip pain. He was seen by a nurse and booked for non-urgent follow-up. He complained of pain in his left hip again in March 2011. On 29 April 2011, he presented to the clinic with left hip pain and was booked for review by the doctor.20
16 Exhibit 2 p 1 17 Exhibit 2 p 7 18 Exhibit 2 p 9 19 Exhibit 1 Volume 2 Tab 11 p 194 20 Exhibit 2 p 19 21 Exhibit 2 p 23 22 Exhibit 2 p 25
Mustafa was transferred to the Metropolitan Remand & Reception Centre (MRRC) in September 2012. On 7 October 2012, he was seen by a nurse. He again complained of back and left hip pain and enquired when he was going to have an MRI. The previously cancelled appointments were noted by the nurse, and there was no future appointment booked. He was placed on a GP waitlist for MRI review.23
Dr Annette Bemand (Justice Health) referred him for an X-Ray of his back on 9 October
This was performed, and it revealed spondylolisthesis, with a moderate narrowing of the L5/S1 disc space and forward shift of L5 vertebra. There was no abnormality reported in Mustafa’s hips or pelvis.24
On 28 October 2012, Mustafa was reviewed by Dr Mari Fleri (Justice Health) at MRRC.
She noted the history of a back injury, and a normal X-Ray from 2010. She noted the result of the latest X-Ray. She examined Mustafa, doing a straight leg raise test for each leg. Mustafa did not let her test his left knee reflexes. Her preliminary diagnosis was that the findings on X-Ray were the cause of Mustafa’s pain in his left leg. She discussed this with him, and recommended physio and analgesics, and a better mattress and footwear; all those were later provided. She also advised that the MRI was not needed.25
Dr Scott (Justice Health) reviewed Mustafa on 24 December 2012, again regarding the left hip. His note records “MRI apparently ordered but cancelled (apparently for security reasons – it appears patient was told whe (sic) his appointment was).” The MRI was to be re-booked.26 Despite that note, there is no evidence an MRI had been booked after the X-Ray taken in October.
At the end of 2012, Mustafa made a complaint to the HCCC regarding the fact that an MRI scan had not occurred.
23 Exhibit 2 p 77 24 Exhibit 2 p 82 25 Exhibit 2 p 87 26 Exhibit 2 p 91
On 12 February 2013, a nurse made enquiries about whether an MRI appointment had been booked. Contact was made with the medical appointments unit, and an email was sent to Dr Scott about it.27
The outcome of that enquiry is not known. However, it does not appear that an MRI was ever re-booked.
Mustafa was also reviewed by Associate Professor Dearin on 14 February 2014. His note records that the 2012 X-Ray had shown mild spondylolisthesis, but that Mustafa’s pain was mild and did not require analgesics. He recommended Mustafa do exercises.28
Ultimately, a CT scan and an MRI scan was performed of Mustafa’s whole spine, when he returned to custody in June 2016. It showed grade 1 anterolisthesis, with narrowing of the nerve canals at L5/S1 (and also at T7/8).29 This effectively confirmed the findings from the X-Ray in 2012.
Dr Andelkovic’s opinion is that the concerns reported by Mustafa dating back to 2010 were not related to the sarcoma. The pain was in the lower back and left buttock which was the wrong location as the sarcoma developed in the front of the thigh. In 2020 when the sarcoma was identified Mustafa said that the lump was not painful. I accept Dr Andelkovic’s opinion that it is unlikely that the lump would have been painful 10 years prior and also not develop into metastatic disease.
I accept Dr Andelkovic’s opinion that the more plausible explanation for the pain in the left thigh, buttock and/or lower back is that Mustafa had spondylolisthesis which was confirmed by X-ray in 2012 and that these symptoms were not related to his ASPS.
(d) Was coughing blood in January 2020 related to Mustafa’s ASPS?
27 Exhibit 2 p 95 28 Exhibit 2 p 104 29 Exhibit 1 Volume 11 Tab 66 p 3808; Exhibit 1 Volume 21 Tab 87 p 7852
(i) On 21 January 2020, Mustafa lodged a self-report, and this was put into the system on 25 January 2020.30 (ii) He was reviewed by a nurse on 27 January 2020.31 Mustafa said he had been unwell and coughing up blood but that he was feeling better.
(iii) The following day he was seen again and put on a waitlist for semi urgent review (within 90 days). On that same day he fractured his hand and was referred to hospital.32 (iv) During this period, he was transferred for X-rays and also simultaneous assessments for his mental health.
(v) On 23 April 2020 he was reviewed by Dr Dearin.33
The period of time from the first report of coughing blood on 14 January 2020 to the first time Mustafa saw a GP on 23 April 2020 was lengthy.
However, Dr Andelkovic informed the court that even if the sarcoma had been discovered earlier in 2020, Mustafa’s treatment and outcome would have been the same. Dr Andelkovic’s conclusion is that, while his treatment would have started earlier, it would not have altered Mustafa’s outcome as the disease had already metastasised.
On 30 April 2020, Dr Dearin identified the lump in Mustafa’s leg, there was a referral for investigation, and it was escalated quickly. By May 2020, scans and biopsies confirmed the diagnosis and treatment commenced.
Dr Andelkovic is of the opinion that the diagnosis and management of Mustafa’s ASPS was appropriate. Following treatment by Pazopanib, there was access to Cediranib from the UK. Dr Andelkovic says this is beyond the level of treatment that patients in the 30 Exhibit 1 Volume 9 Tab 63 p 3108 31 Exhibit 1 Volume 13 Tab 66 p 5005 32 Exhibit 1 Volume 13 Tab 66 p 5007 33 Exhibit 1 Volume 14 Tab 66 p 5061
community can receive. He concluded that the management of Mustafa’s sarcoma was best practice or better.
The earliest resuscitation plan was recorded on 13 June 2021, by Dr David Golstein at POWH.34 He noted that at that stage Mustafa wished to have all curative options, despite no chance of benefit. The resuscitation plan recorded that, while he would be provided with respiratory support and oxygen, he would not be provided with ventilation, intubation or CPR in the event of a cardiac arrest.
On 5 August 2021, Dr Bhadri reviewed Mustafa.35 He informed Mustafa about his prognosis. It appeared Mustafa’s disease was progressing despite treatment with Pazopanib.
Following this, there were further end of life discussions between Justice Health staff, Mustafa and his family.
On 5 October 2021, Dr Spasojevic (Justice Health) discussed a resuscitation plan with Mustafa and his mother. Mustafa wanted to speak to his family about it, and his mother wanted to speak with her GP.36
Dr Spasojevic spoke to Mustafa the following week on 11 October 2021. Mustafa said he was scared of dying and wanted to speak to an Imam. The doctor explained end of life care and reassured him they would make him comfortable. Mustafa asked that his mother be updated.37 This was done the following day by Dr Spasojevic,38 and the Imam visited on 12 October 2021.39
On 15 October 2021, Dr Joanne Grimsdale (Justice Health) had a discussion with Mustafa about the resuscitation plan. He asked to speak to the doctor without his mother present. Dr Grimsdale discussed possible treatment options and the likely 34 Exhibit 1 Volume 22 Tab 89 p 8334 35 Exhibit 1 Volume 10 Tab 65 p 3751-2 36 Exhibit 1 Volume 18 Tab 66 p 6798 37 Exhibit 1 Volume 18 Tab 66 p 6834 38 Exhibit 1 Volume 18 Tab 66 p 6842 39 Exhibit 1 Volume 18 Tab 66 p 6842
consequences. She provided him with a copy of the resuscitation plan document.
Mustafa said he would consider what they had discussed and wanted another meeting with his mother the following week.40
On 19 October 2021, there was a multidisciplinary meeting with staff from Justice Health and POWH, including Dr Bhadri, Dr Spasojevic and Dr Strutt.41 The meeting agreed that CPR was not appropriate for Mustafa, although he would be provided with proactive treatment, including Cediranib.
That day, a resuscitation plan was completed for Mustafa. It recorded that Mustafa was to receive symptomatic management, chemotherapy, comfort measures, respiratory support including oxygen, but no ventilation or intubation, and no CPR in the event of a cardiac arrest. It was considered that CPR would provide negligible clinical benefit.42
Mustafa did not participate in the meeting on 19 October 2021 and did not agree with the decision not to conduct CPR. Mustafa remained optimistic and hoped he could survive for a long time. Treating clinicians took a different view. The NSW Health Policy ‘Using Resuscitation Plans in End of Life Decisions’ did not require a patient’s consent to a resuscitation plan.43
Despite this, there was still active treatment pursued for Mustafa. Drugs arrived from UK and were provided to him into January 2022. The plan remained in place until the time Mustafa entered POWH. On 13 January 2022, a further resuscitation plan in substantially the same terms was recorded. That remained in place until Mustafa’s death.44
40 Exhibit 1 Volume 18 Tab 66 p 6862 41 Exhibit 1 Volume 18 Tab 66 p 6897 42 Exhibit 1 Volume 10 Tab 66 p 3552-3 43 Exhibit 3 p 10 44 Exhibit 1 Volume 22 Tab 89 p 8544
Mustafa’s mother first participated in a meeting with Associate Professor Dearin on 30 April 2020, when the ASPS diagnosis was first identified.
Mustafa’s mother wishes that she could have been involved in MDT meetings as envisaged in the NSW Health Palliative Care – Model of Care. That model of care is not specific to Justice Health. The Court has been informed that there are security issues with family attending MDT meetings in relation to persons in custody.
I was pleased to note that there were then at least 15 occasions from June 2020 to December 2021 where clinicians explicitly record that they had conversations with Mustafa’s mother to update her on his treatment and what the plan was, including communications with the palliative care team, the treating oncology team, and a geneticist in relation to whether he would have a family history of ASPS.
I am satisfied that appropriate steps were taken to include Mustafa’s mother in his care.
Since Mustafa’s death, the NSW Health End-of-Life Care policy was updated to further enhance its provisions. The new policy is grounded in the principles of building consensus, respect for life and care in dying, the right to know and to choose, appropriate withholding and withdrawal of life sustaining treatment, a collaborative approach to care, transparency and accountability, non-discriminatory care, rights and obligations of health practitioners and continuous improvement
The new policy includes provisions to assist with preventing and resolving disagreements which may arise in circumstances where the patient and family and the treating team all must come to an agreement regarding appropriate medical management when a patient is dying.
Throughout 2024, the Justice Health NSW Palliative Care Team transitioned into the Allied Health Palliative and Aged Care Team. Within this team there has been the creation of an allied health palliative and aged care social work position. The duties of this role include providing psychosocial support and counselling to palliative care patients and their families, to advocate support and educate patients and their families around of end-of-life planning and improving quality of life and to support access to
NSW Trustee and Guardian to plan and make wills Enduring Power of Attorneys and Enduring Guardianship.
It is important to ensure that the end of life of a person in custody is dignified. Mustafa’s mother has been concerned to know that all that could have been done for him was done appropriately. I offer my condolences and sympathy to Mustafa’s family.
I thank counsel assisting, Mr Jake Harris and his instructing solicitor Katherine Chow from the Coroner’s Court Secondment Unit for the work they put into assisting me in this inquest. I would also like to acknowledge the work of Detective Senior Constable Rianna Malvern who performed the role of Officer in Charge of the Police investigation.
SECTION 81 CORONERS ACT (2009) FINDINGS: Identity The person who died was Mustafa Kayirici.
Date of death Mustafa died on 25 January 2022.
Place of death Mustafa died at the Prince of Wales Hospital, Randwick, NSW.
Cause of death The cause of Mustafa’s death was alveolar soft part sarcoma.
Manner of death Mustafa died as a result of natural causes while he was in lawful custody.
Magistrate Carmel Forbes Deputy State Coroner Coroners Court of NSW, Lidcombe 10 March 2026
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