Deceased
Valerie Margaret Fraser
Demographics
94y, female
Coroner
Coroner Darren Bracken
Date of death
2017-11-24
Finding date
2021-04-30
Cause of death
Complications of metastatic lobular carcinoma of the breast in a woman with dementia
AI-generated summary
A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was not diagnosed until 15 November 2017, two weeks into her final admission. A critical error occurred on 6 November when GMU clinicians mistakenly told the family that a CT scan had already been performed, when in fact no such scan had been done. This communication error delayed appropriate imaging. However, the coroner found that earlier diagnosis would not have changed management—seven separate clinical teams, including senior gastroenterologists and medical oncologists, all independently recommended palliative care only. Surgery, chemotherapy, and stenting were deemed inappropriate due to the patient's extreme frailty, advanced dementia (ECOG score 4), and terminal cancer status. The key clinical lesson is the importance of accurate communication about diagnostic investigations and documentation, though in this case, the error did not alter the inevitable outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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