Coroner's Finding: SEMMLER Howard Malcolm

60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic malignant melanoma

A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressing, antibiotics, and orthopaedic review. Malignant melanoma was diagnosed only in July 2008 following biopsy, at which point the cancer had already metastasised to regional lymph nodes. The melanoma subsequently spread to the pleura and lungs, causing pleural effusion. The patient died in November 2008 from cardiorespiratory failure. Key clinical lessons: plantar melanomas are frequently misdiagnosed as diabetic ulcers, particularly when there is preceding trauma; non-healing ulcers warrant review by medical practitioners within 4-6 months to consider malignancy; multidisciplinary foot clinics improve diagnostic accuracy; and better communication between primary care, podiatry, and specialists is essential.