AN INQUEST INTO THE DEATH OF ROBERT DOUGLAS

67y · Male·respiratory failure with antecedent causes including chronic emphysematic lung disease, inflammatory lung damage possibly from radiation therapy, and acute respiratory infection of unknown type and origin

67-year-old male with 40-year smoking history presented with chest symptoms in 2012. CT scan revealed a left upper lobe mass. Core biopsy was incorrectly reported as adenocarcinoma by the pathologist, despite clinical uncertainty. The patient received 6 weeks of chemo-radiotherapy. Post-treatment, a mass developed in the chest wall. He subsequently developed respiratory infection and died from respiratory failure. Autopsy revealed no cancer cells in the original biopsy sample—a diagnostic error. Key lessons: A quality assurance system failed due to Easter timing, preventing second pathology review. Clinicians appropriately relied on the initial biopsy. The treatment administered was appropriate given the clinical presentation. Poor documentation of multidisciplinary meeting outcomes and incomplete autopsy supervision contributed to information gaps.