Finding into death of Ms S

63y · Female·Sepsis complicating cellulitis following skin cancer excision and skin graft procedure in a woman with multiple medical comorbidities (palliated)

A 63-year-old woman died from sepsis complicating cellulitis following elective skin cancer excision and skin graft performed in a general practitioner's clinic. The lesion was a squamous cell carcinoma (invasive Bowen's disease) on the lower leg. Two days post-procedure, the patient presented with fever, delirium, and lower limb cellulitis. Despite appropriate intravenous antibiotics, she deteriorated with secondary myocardial injury and was transitioned to palliative care. The Coroner's Prevention Unit reviewed the case and found the GP's management appropriate—skin lesion excision by experienced GPs in clinic is standard practice, prophylactic antibiotics are not routine for non-infected lesions, and the causative organism (pseudomonas) would not have been prevented by standard prophylaxis. No prevention opportunities were identified.