Coroner's Finding: Jackson, Dennis Charles
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.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Contamination of biopsy sample with squamous cell carcinoma tissue from another patient
- Inadequate cleaning of embedding forceps between specimens
- Unnecessary left upper lobe lobectomy performed based on false diagnosis
- Post-operative complications including hospital-acquired pneumonia and ventilator-associated pneumonia
- Vocal cord injury from surgery affecting swallowing and coughing ability
- Policy requiring only wiping rather than flaming of forceps between samples
- Lack of scrutiny of 'free-floating fragment' finding at multidisciplinary team meeting
Coroner's recommendations
- The Minister for Health and Wellbeing should engage an external scientist to conduct an independent review of SA Pathology's anatomical pathology laboratories to provide recommendations on how procedures and practices can be improved to reduce the risk of cross-contamination, specifically considering Professor McLean's opinion on intense instrument flaming between biopsy samples.
- The Minister for Health and Wellbeing should ensure so far as is reasonably practicable that all recommendations made as a result of that review are implemented across all SA Pathology laboratories.
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