Coroner's Finding: PETERS Clinton Neal
Deceased
Clinton Neal Peters
Demographics
40y, male
Date of death
2015-09-02
Finding date
2019-03-08
Cause of death
metastatic malignant melanoma
AI-generated summary
A 40-year-old man with metastatic melanoma died at Queen Elizabeth Hospital on 2 September 2015. He had atypical nevi removed in 2009 and melanoma diagnosed in 2013, initially undergoing surgery with curative intent. However, he had poor follow-up compliance with melanoma clinic appointments. In June 2015, he presented to the ED three times over two weeks with pain; initial assessments were inadequate and did not identify metastatic disease until the third presentation. Brain metastases and C6 spinal involvement were subsequently found. During terminal admission, he developed confusion and agitation from brain metastases and pain, necessitating an Inpatient Treatment Order. The coroner noted the initial ED assessments were suboptimal but unlikely to have changed the outcome. Key clinical lessons include: ensuring thorough assessment of cancer patients with new symptoms; importance of follow-up compliance systems; and recognizing that confusion in advanced cancer may reflect disease progression rather than primary psychiatric pathology.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- inadequate initial assessment at Emergency Department in June 2015
- delay in diagnosis of metastatic disease
- poor follow-up compliance with melanoma clinic after initial surgery
- confusion and agitation secondary to brain metastases and pain
- cognitive deterioration affecting capacity and decision-making
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