Finding into death of Susan Ruth Lovell

60y · Female·Complications of metastatic melanoma in the setting of neck of femur fracture following a fall (operated and palliated)

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.