Recommendations and treatment plans from oncology multidisciplinary team (MDT) meetings should not be left to junior doctors to write up, a coroner has recommended following the death of a cancer patient who was given the wrong treatment.
An inquest in Perth concluded that a breakdown in communication at the Fiona Stanley Hospital in 2017 meant that a 73 year old man did not receive the most appropriate chemotherapy to augment radiotherapy for his lung cancer, nor did he receive radiotherapy or chemotherapy following the surgical removal of his oral cancer.
It was alleged that confusion arose between treatment recommendations from medical oncology, head and neck cancer and respiratory medicine treatment teams, which resulted in the patient being treated with cetuximab when he should have been given carboplatin and etoposide, the standard agents used for lung cancer.
The WA coroner found that one contributing factor to the mixup was that taking notes and circulating a summary of the MDT discussions and outcomes were sometimes delegated to the most junior doctors and their inexperience meant the treatment plans were “not as comprehensive or as accurate as might be desirable.”
“In my view, given that MDTs are a crucial aspect of the management of cancer patients, it is essential that notes published after such meetings are of the highest possible quality. Amongst other things, this is because MDT notes are relied on by clinicians to access clinical information, including the patient’s most recent treatment plan.”
“It follows that rather than delegate the admittedly onerous task of taking notes at MDTs to the most junior attendee, the task should be undertaken by a suitably experienced clinician, perhaps an experienced registrar or a clinical nurse specialist. Where this is not possible then, as noted earlier, an experienced practitioner who attended the relevant MDT should carefully review the draft MDT notes before they are published.”
The coroner noted that while the error did not affect the patient’s ultimate outcome, the hospital had said it had since changed its systems to ensure that medical oncology teams received more detailed radiotherapy treatment plans.
The inquest also acknowledged the complexity involved in treatment for two concurrent cancers and heard that it may have be preferable in such cases for treatment to be supervised by a single oncologist or Complex Cancer Care Coordinators.
“It seems likely that had Mr Craig’s care been supervised by a Care Coordinator, the errors that occurred in his treatment would have been identified at a much earlier point,” he said.
The treatment error risk was also increased by communication breakdowns due to different departments using incompatible computer systems, the inquest heard. This might be remedied by the use of a single “Oncology Information System”, the coroner suggested.