Non-inquest findings into the death of SD

Contributing factors

• Misdiagnosis of Hodgkin lymphoma instead of peripheral T-cell lymphoma
• Critical PAX5 immunohistochemistry result not presented to MDT meeting on 4 May 2023
• Cytology result showing atypical T-cell proliferation not reviewed by treating team or discussed at second MDT meeting
• Lack of standardised process for tracking onsite second pathology opinion requests
• Immunohistochemistry testing (PAX5) not available onsite; offsite delays in reporting
• Pathology result not flagged as critical diagnosis variance despite significant implications for treatment
• Gaps in pathology result review and endorsement by haematology team
• MDT process lacked clear follow-up plan for incomplete diagnoses
• Pathology workload pressures and staff shortages affecting second opinion completion and MDT preparation
• Part-time pathologist position with no backfill for leave
• Ryan's Rule escalation not actioned with appropriate senior clinical review
• Lack of immediate response to family concerns and clinical deterioration

Coroner's recommendations

1. Pathology Queensland to review processes for onsite second opinion diagnosis and establish minimum standard for tracking and completion of requests
2. Hospital Cancer Care Directorate to liaise with onsite Pathology Queensland laboratory to increase suite of specialised immunohistochemistry markers including PAX5 to be performed onsite
3. Pathology Queensland to review procedure for notifying critical diagnoses to ensure phone call to treating team when diagnostic variance has significant implications for patient care
4. Haematology unit to review pathology review and management processes to ensure all pathology reports are reviewed for all patients
5. Haematology unit to review MDT process including clear roles and responsibilities, case selection, reduction of cases per meeting, clear documentation of plans and responsibilities, mandatory attendance by specialty experts, and measures to minimise cognitive bias
6. Hospital and Health Service to ensure Ryan's Rule activations result in full clinical review by appropriate senior clinician and include consideration of second opinion
7. Implementation of Monday morning haematology team meetings with multidisciplinary participation to raise concerns
8. Change medical team rotations from weekly to fortnightly to improve continuity of care
9. Requirement for all high-risk pathology and imaging results to be ordered under Senior Medical Officer name to ensure result return to responsible clinician
10. Requirement for timely local review of all inpatient falls with family notification
11. Improvement to inpatient telehealth with bedside support