QLDhospital

Gerhardt, Robert John

Deceased

Robert John Gerhardt

Demographics

44y, male

Coroner

Barnes

Date of death

2011-05-06

Finding date

2012-12-19

Cause of death

Metastatic small cell neuroendocrine carcinoma of lung

AI-generated summary

Robert Gerhardt, 44, died of metastatic small cell lung cancer on 6 May 2011 at Princess Alexandra Hospital, shortly after receiving compassionate parole. He had presented to PAH emergency department on 28 September 2010 with respiratory symptoms. A chest x-ray that day revealed a mediastinal density reported by radiology as possibly requiring CT investigation, but this was not followed up for nearly two months until diagnosis was made on 22 November 2010. While the coroner found the delayed diagnosis would not have changed the outcome (cancer was already advanced), the failure to act on the radiology registrar's report represents a missed diagnostic opportunity. Additionally, in February 2011, Mr Gerhardt requested morphine for chest pain but was given only paracetamol by nursing staff; the coroner found this acceptable as nursing staff could not administer morphine without physician approval, though the request could have been escalated.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

oncologyemergency medicineradiologypalliative carecorrectional health

Error types

diagnosticcommunication

Drugs involved

oxycodoneoxycodoneparacetamolmorphine

Clinical conditions

metastatic small cell lung cancerasthmachest paincancer-related pain

Procedures

chest X-rayCT imaging (recommended but not performed initially)chemotherapy

Contributing factors

Failure to follow up radiology findings on 28 September 2010
Chest x-ray initially reported as 'clear' by intern despite abnormality noted by radiology registrar
No action taken on registrar's recommendation for CT imaging to exclude mediastinal lesion
Approximately two-month delay between initial radiological finding and diagnosis
Inadequate pain management on 25 February 2011 when morphine request was declined

Coroner's recommendations

Princess Alexandra Hospital to implement systems to identify missed abnormal radiology findings, either through manual review of finalised radiology reports by senior emergency department staff cross-referenced with patient attendance records, or through an electronic solution based on the radiology PACS system to notify patients, GPs, or correctional facility staff of missed abnormalities with recommendations for follow-up

Full text

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