On 10 September 2021 I commenced an investigation into the death of Gary STARBUCK aged 81. The investigation concluded at the end of the inquest on 12 December 2025. The conclusion of the inquest was: Narrative Conclusion - Gary STARBUCK was a much loved and desperately missed member of his Family. He was a man who had a great zest for life, a keen and energetic sportsman, something he managed to sustain well into his 70’s. Mr. Starbuck was known for his warm, welcoming hospitality, an optimistic man with a fantastic dry sense of humour. He was one of those people who would make a person feel uplifted by having been in his company. His Family recalls him as someone who could be relied upon to radiate calmness in a crisis and was always there to support his children, his broader Family and friends. He was loyal, kind, generous and fair. A person who during his life had a significant, positive impact on the lives of those around him. During his life, Mr Starbuck had spent time living in Australia where he had been exposed to the effects of the sun and this is likely to have resulted in damage to his skin which subsequently led to him contracting skin lesions in the form of basal and squamous cell carcinomas. Mr. Starbuck’s previous medical history included a diagnosis of hypertension and hairy-cell leukaemia, the latter diagnosed in 2006 and for which he received treatment including chemotherapy. He had suffered a cerebrovascular accident in 2017. Due to his diagnosis of and treatment for hairy-cell leukaemia, Mr. Starbuck suffered from immunosuppression which impacted on his subsequent treatment and increased his risk of contracting further disease. As a consequence, Mr. Starbuck presented as a patient with complex considerations for his clinical care and management. Between 2011 and 2017 Mr. Starbuck underwent numerous procedures to excise skin lesions which were believed to be due to previous sun exposure. In January 2017 he underwent an excision on his right pinna (ear) for what was believed to have been a basal cell carcinoma. Subsequent pathology analysis determined that this was in fact a squamous cell carcinoma. The clinician performing this procedure assessed at the time that this tumour had been completely excised although close to acceptable margins. In January 2018 a tumour was identified again on the right pinna and which was excised. Further testing determined that the tumour was a squamous cell carcinoma which had not been successfully excised within clinical margins. Two subsequent attempts to excise this tumour in March and June 2018 were unsuccessful. The care and treatment for Mr. Starbuck in relation to this squamous cell carcinoma and ongoing treatment for other skin cancers was transferred to another clinician in June 2018. Mr. Starbuck underwent radiotherapy treatment which seemed to cure the tumour and he experienced a period of time where there appeared to be no recurrence of this tumour. During this time Mr. Starbuck continued to experience other skin lesions which were treated. In May 2020 it was assessed that the squamous cell carcinoma which had been treated in 2018 had recurred and metastasised to Mr. Starbuck’s lungs. Further intensive treatment, including re-irradiation and immunotherapy were sadly unable to cure the cancer and it metastasised further to Mr. Starbuck’s neck. Mr. Starbuck’s care transitioned in July 2021 from curative to palliative care and he died at home on the 16th August 2021. A post-mortem examination of Mr. Starbuck’s body established that his medical cause of death was due to Metastatic Cutaneous Squamous Cell Carcinoma. Gary STARBUCK died due to the metastases of a cutaneous squamous cell carcinoma, a naturally occurring condition. The medical cause of death was confirmed as: 1a Metastatic Cutaneous Squamous Cell Carcinoma

Narrative Conclusion see Box 4