Coroner's Finding: SEMMLER Howard Malcolm
Deceased
Howard Malcolm Semmler
Demographics
60y, male
Date of death
2008-11-14
Finding date
2011-08-05
Cause of death
cardiorespiratory failure due to malignant pleural effusion due to metastatic malignant melanoma
AI-generated summary
A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressing, antibiotics, and orthopaedic review. Malignant melanoma was diagnosed only in July 2008 following biopsy, at which point the cancer had already metastasised to regional lymph nodes. The melanoma subsequently spread to the pleura and lungs, causing pleural effusion. The patient died in November 2008 from cardiorespiratory failure. Key clinical lessons: plantar melanomas are frequently misdiagnosed as diabetic ulcers, particularly when there is preceding trauma; non-healing ulcers warrant review by medical practitioners within 4-6 months to consider malignancy; multidisciplinary foot clinics improve diagnostic accuracy; and better communication between primary care, podiatry, and specialists is essential.
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Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- delayed diagnosis of malignant melanoma (16 months between presentation and biopsy)
- misdiagnosis of melanoma as diabetic foot ulcer
- lack of medical review of non-healing ulcer
- preceding trauma history diverting diagnostic attention away from malignancy
- lack of communication between general practitioner and podiatrist
- absence of multidisciplinary foot clinic at Modbury Hospital
- rapid metastatic spread to groin, pleura, and lungs
Coroner's recommendations
- The Australian Health Practitioner Regulation Agency should draw to the attention of the medical profession and the podiatry profession the need to medically review and re-evaluate the diagnosis of foot ulcers that fail to heal within an expected time frame
- The Australian Health Practitioner Regulation Agency and the Australian Medical Association (SA) should draw this matter to the attention of the wider medical and allied health professions for the purposes of education
- The Minister for Health and the responsible person at the Modbury Hospital should give consideration to establishing a multi-disciplinary clinic, such as those that exist in the Lyell McEwin Hospital, the Royal Adelaide Hospital, the Queen Elizabeth Hospital and the Flinders Medical Centre, that is designed to manage, treat and properly diagnose foot ulcers in a timely manner
- The Minister for Health should give consideration to the establishment of the role of a 'patient advocate' within the public health system to promote better communication between patient's family members and clinicians and to avoid tension between the wishes of a patient's family members and the clinical opinions and judgments made by medical practitioners responsible for the patient's management
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