Coroner's Finding: Sears, James Frank

53y · Male·disseminated malignant melanoma

A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary team meeting recommended wide local excision and lymph node dissection, but this critical surgery was never performed due to communication breakdown between dermatology and surgical oncology. By May 2020, extensive metastatic disease had developed. The coroner found that had the recommended surgery occurred as planned, the patient had a 65% chance of five-year disease-free survival. The standard of care was unsatisfactory; systemic failures in MDT communication and follow-up directly contributed to a preventable death.