AN INQUEST INTO THE DEATH OF ROBERT DOUGLAS

Contributing factors

• incorrect pathology diagnosis of benign tissue as adenocarcinoma
• failure of quality assurance review process due to Easter long weekend
• chemo-radiotherapy treatment based on incorrect diagnosis
• post-treatment chest wall infection and necrosis
• emphysematous lungs from long smoking history
• prolonged uncontrolled respiratory infection

Coroner's recommendations

1. The Canberra Hospital continue to periodically review its quality assurance processes for core biopsies, to ensure that such processes appropriately balance the need to minimise the risk of errors with the costs of associated control measures. Such processes should involve an element to check and ensure compliance.
2. The Peter MacCallum Cancer Institute consider reviewing the words used within its reports for the Epidermal Growth Factor Receptor Mutation Analysis to ensure that treating clinicians are disabused of any erroneous assumption that the test either reassesses the original diagnosis or positively identifies tumour cells.
3. The Canberra Hospital consider introducing a protocol that require appropriate records be made of Lung Multidisciplinary Meetings, and that such records be appropriately stored.