Coronial
VIChospital

Finding into death of Susan Ruth Lovell

Deceased

Susan Ruth Lovell

Demographics

60y, female

Coroner

Coroner Rosemary Carlin

Date of death

2013-10-24

Finding date

2016-03-02

Cause of death

Complications of metastatic melanoma in the setting of neck of femur fracture following a fall (operated and palliated)

AI-generated summary

Susan Ruth Lovell, a 60-year-old woman, died from complications of metastatic melanoma in the setting of a neck of femur fracture sustained during a fall. A skin lesion on her left calf, noted in January 2010, was clinically diagnosed as benign seborrhoeic keratosis by dermatologist Dr R.. When excised by GP Dr S. in December 2010, the tissue was not sent for histopathological assessment despite the patient's ongoing concern. Melanoma with groin metastases was subsequently diagnosed in 2011. The coroner found Dr R.'s initial assessment reasonable and consistent with standard practice, but noted it would have been prudent for Dr S. to send the excised lesion for histology. The primary site of melanoma remains unknown. Additionally, despite appropriate falls prevention measures at Alfred Hospital, Mrs Lovell fell from her bed postoperatively; a proximity sensor alarm was not used alongside constant observer supervision, missing an opportunity for additional protection.

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Specialties

general practicedermatologysurgeryoncologyneurosurgery

Error types

diagnosticsystem

Drugs involved

sertralinemorphineclonazepaminterferonoral chemotherapy

Clinical conditions

metastatic melanomamelanoma with unknown primary siteseborrhoeic keratosisbasal cell carcinomabrain metastaseshydrocephalusneck of femur fractureileushyponatraemiaurinary tract infectiondeliriumseizuredepression

Procedures

skin lesion excisionfine needle aspirationgroin lymph node dissectioncalf re-excisionlumbar punctureventricular peritoneal shunt insertiondynamic hip screw insertion

Contributing factors

  • Failure to send excised skin lesion for pathological assessment
  • Missed or delayed diagnosis of melanoma (primary site never identified)
  • Fall from bed in hospital despite 'super high' falls risk assessment
  • Constant observer distracted by paperwork at time of fall
  • Absence of proximity sensor alarm in conjunction with constant observer supervision
  • Post-operative confusion and ataxia following VP shunt procedure

Coroner's recommendations

  1. Royal Australian College of General Practitioners consider circulating educational material to members regarding best practice in management of skin lesions, including after excision
  2. Royal Australian College of General Practitioners consider establishing guidelines for best practice when a skin lesion has been excised, even after being clinically diagnosed as benign
  3. Royal Australian College of General Practitioners continue educating members on the importance of comprehensive contemporaneous clinical notes
  4. Alfred Health amend policies to require use of Proximate or similar sensor alert devices in conjunction with visual observations by Constant Patient Observer or nursing staff when patient assessed as very high falls risk
Full text

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