Inquest into the Death of Robert Charles CRAIG

Contributing factors

• Failure to arrange post-operative radiotherapy for oral cancer following surgical removal
• Administration of inappropriate chemotherapy (Cetuximab for lung cancer instead of carboplatin and etoposide)
• Poor communication between Medical Oncology and Radiation Oncology departments
• Delayed transmission of critical clinical correspondence (61-day delay in Dr T.'s letter)
• Incompatible computer systems (BossNet and MOSAIQ) limiting information sharing
• Suboptimal multidisciplinary team note documentation
• Inadequate care coordination for complex multi-cancer case
• Insufficient complex cancer care coordinators
• Reliance on junior staff for MDT note-taking without supervision
• Unclear e-referral communication regarding treatment modality

Coroner's recommendations

1. To ensure the accuracy of notes and treatment plans recorded following multidisciplinary team meetings (MDT) held at Fiona Stanley Hospital, MDT notes should be taken by a suitably experienced clinician or health practitioner. Where this is not possible, MDT notes should be checked by a suitably experienced clinician prior to being circulated.
2. To ensure that referrals are triaged appropriately and in a timely manner, the e-Referral system used at Fiona Stanley Hospital should be modified to include a text box requiring the referring clinician to state the reason for the referral and, in general terms, the nature of the treatment or service being requested.
3. Urgent liaison between South Metropolitan Health Service and the Western Australian Health Department to prioritise implementation of a state-wide Oncology Information System (OIS).
4. South Metropolitan Health Service should support employment of additional Complex Cancer Care Coordinators at Fiona Stanley Hospital across cancer specialties.