Coroner's Finding: Sears, James Frank

Contributing factors

• failure to action multi-disciplinary team recommendations for wide local excision and lymph node dissection in January 2020
• communication breakdown between RAH dermatology and surgical oncology departments
• lack of systemic follow-up mechanism to ensure MDT recommendations were implemented
• delay in treatment resulting in progression from Stage III to extensive metastatic disease by May 2020
• absence of clear booking and appointment system following MDT meeting

Coroner's recommendations

1. MDT meeting processes be reviewed and a clear system established for documenting, communicating, and following up upon Multi-Disciplinary Team recommendations across SA Health
2. Recommendations following RAH MDT are clearly recorded
3. Clinical Summary of MDT including recommendations is sent to referring clinician with copies to other relevant clinicians
4. General practitioner or primary care doctor (including prison doctors) should receive copy of MDT summary; recommendations should be clearly labeled as advisory
5. MDT Clinical Summary filed in patient's clinical records in easily locatable location in main EMR system
6. MDT Chair checks that appointment has been made in respective clinic for next stage of management
7. MDT Chair follows up when patient is listed for discussion, with alert on EMR system especially where actions are required