Deceased
Dennis Charles Jackson
Demographics
67y, male
Date of death
2019-01-21
Finding date
2025-11-05
Cause of death
Type 2 respiratory failure due to pneumonia
AI-generated summary
Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pathology. The contamination occurred at 2:50am on 26 July 2018, likely due to inadequate cleaning of embedding forceps between specimens. The pathology report describing a 'free-floating fragment' of SCC was not questioned at the subsequent multidisciplinary team meeting despite clinical improbability. Jackson's surgery never would have occurred without this misdiagnosis. He suffered serious post-operative complications including hospital-acquired pneumonia, ventilator-associated pneumonia, dysphagia requiring PEG feeding, and vocal cord injury. After 63 days in ICU, he died from type 2 respiratory failure due to pneumonia. Clinical lessons: pathology reports should trigger discussion when findings appear inconsistent with clinical picture; contamination prevention requires mandatory flaming of instruments between samples, not merely wiping; external review of laboratory procedures is essential.
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Specialties
Error types
Clinical conditions
Procedures
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