Inquest into death of Dennis Charles Jackson hears reason for unnecessary surgery

A RAH patient had part of his lung removed unnecessarily after a lab sample error and later died from pneumonia. Read the apology letter sent to a man whose death could have been avoided.

A minute fragment of cancerous tissue which contaminated a sample of a healthy lung led to a 67-year-old man having the top left part of his lung removed unnecessarily, an inquest has heard.

Dennis Charles Jackson died on January 21, 2019, from advanced pneumonia after spending more than two months in hospital less than a year after the surgery.

After his misdiagnosis and the removal of part of his lung, he was issued with an apology letter which said “errors like this are rare”.

Dennis Jackson with wife Ramonda with their great nephew Paxton Williams. Picture: Supplied

The letter of apology sent to Dennis Charles Jackson following a mistake which led to unnecessary surgery which removed part of his lung. Picture: Coroner’s Court

Deputy Coroner Ian White opened an inquest into Mr Jackson’s death on Tuesday and will focus on how the contaminant got into the tissue sample and whether the subsequent unnecessary surgery led to his death.

Mr Jackson – who was known to friends as Jacko – spent most of his life in Broken Hill and had worked in the mines and at the local power station.

In 2017 Mr Jackson had gone to his doctor complaining of weight loss and shortness of breath.

A subsequent scan of his lungs identified a needle-shaped growth of tissue in the top of his left lung and a nearby “satellite” mass.

Mr Jackson was referred to a specialist who concluded that the chances of the nodule and its satellite being cancerous were low and thought it was more likely to be a granuloma – a small inflammation often seen on X-rays which are non-cancerous.

However, to be sure, a needle was inserted into Mr Jackson’s lungs and several samples of the nodule were removed and sent to the Royal Adelaide Hospital anatomical pathology department.

On analysis in the lab, a technician located a free-floating cancerous cell in one of the five samples.

The discovery led to the conclusion that Mr Jackson had a malignant cancer in the top of his lung which would need to be removed.

On August 17, 2018, Mr Jackson underwent major surgery where the top “lobe” of his lung was removed.

However, when it was taken to the lab for analysis the mass in the lung was found to be a granuloma and the rest of the sample was healthy.

An internal investigation found that the cancerous cells were a contaminant from a previous sample and belonged to a different patient.

Representatives from the Central Adelaide Local Health Network formally apologised to Mr Jackson and his family in two different meetings and by letter.

In the letter, Head of the Department of Anatomical Pathology, Dr Sophia Otto, said she was aware the incorrect diagnosis had led to unnecessary surgery which “has caused anguish for your and your family and I am sorry that this has occurred”.

“Upon investigation, I have found that the error was caused during the processing of the tissue at the tissue embedding stage,” she said.

“Errors like this are rare but nonetheless it is critical that we review our practices and implement further changes so that the risk of such an event occurring in the future is reduced.”

Mr Jackson was discharged from hospital on August 30, 2018, but told his family he was having trouble swallowing and could not taste or smell anything.

He had a cough when he left hospital which grew increasingly worse and on September 25, 2018, he was taken to hospital by ambulance.

Dennis Jackson's niece, Tanya Williams, leaves the Coroner's Court on February 7.

He was diagnosed with hospital-acquired pneumonia. A post mortem would later find that Mr Jackson’s left vocal chords had been damaged, likely during the surgery, making him more susceptible to pneumonia.

Mr Jackson spent more than 60 days in the intensive care unit before being sent back to the ward where he died.

Opening the inquest, counsel assisting the Coroner, Emma Roper, said the diagnosis, the role of the surgery and the impact of the contaminant would be analysed during the hearings.

Expert anatomical pathologist Professor Catriona McLean AO told the court pathology procedures at the RAH lab – which refers to “wiping” forceps between samples – was “not as detailed as it should be”.

“Nowhere is it considered satisfactory to wipe embedding forceps clean,” she said.

Instead, she said a “critical step” of the process in labs around the country was “flaming” – where any remaining tissue is burnt off to avoid extraneous tissue transfer – but that did not appear in the lab’s procedure policy.

She said cross contamination was “definitely something that happens” at pathology labs with international studies indicating a 3 per cent rate of cross contamination.

Outside court, Mr Jackson’s niece Tanya Williams said she hoped the inquest would lead to SA pathology’s procedures becoming “a lot more thorough”.

“I hope they stand up and take a lot more responsibility for handling people’s lives,” she said.

She described Mr Jackson’s journey through the hospital system as like repeatedly “getting hit by a train”.

She said his time in hospital was “shocking” and difficult because he was separated from his family, who lived in Broken Hill, where he was a “well-liked, well-known” man.

“He was friendly with everybody. He got along with anyone and everybody,” she said.

“He was just a wonderful, loving man. A beautiful man.

“He was so funny, he just loved to make people laugh and he had a great sense of humour. (He was) very open, very honest, straight to the point, just a wonderful trusting person.”

She said his lengthy hospital stay and death had shocked a lot of people and about 400 had attended his funeral.

“It was a bit hard to explain to people what had happened,” Ms Williams said.

She said her uncle was a carer for his wife, Ramonda Jackson, and that the couple had previously lost their only son, Luke Jackson, to cancer. Mrs Jackson died months after her husband.

The inquest continues.