Inquest into the Death of Corazon Contreras KEELEY

Contributing factors

• failure to respond appropriately to first histopathology report recommendation for further sampling
• failure to recognize concerning lesion during hysteroscopy despite visible abnormalities on images
• mischaracterization of histopathology results as 'nil abnormal' when they indicated possible atypical glandular epithelium
• inappropriate discharge from gynaecology care after first HDC
• delayed notification of cancer diagnosis to patient (8 days post-confirmation)
• lack of consultant handover for ongoing cases during leave
• absence of systematic notification that pathology results are available
• delayed and inadequate open disclosure to patient and family
• fragmented care across multiple hospital sites

Coroner's recommendations

1. Implementation and prioritization of funding for Electronic Medical Record (EMR) system across public hospitals to ensure pathology results are acted upon in a timely manner with built-in checks and balances
2. Establishment of systematic notification processes when pathology results become available to clinicians
3. Formalization of handover procedures for ongoing patient cases when consultants take leave, particularly for cases where pathology results are pending
4. Enhanced education and training for all staff regarding open disclosure processes and requirements of the Australian Open Disclosure Framework
5. Implementation of dedicated specialist clinics for post-menopausal bleeding with nurse coordinators ensuring timely follow-up (now in place)
6. Establishment of weekly clinics for registrars to manage outstanding gynaecology results and chart-outs
7. Creation of multi-disciplinary team meetings to review complex gynaecology cases fortnightly
8. Establishment of mortality and morbidity meetings in gynaecology to discuss complications and trended data
9. Creation of hysteroscopic-specific outpatient clinics for post-menopausal bleeding with review within one month