Coroner's Court of Western Australia

Inquest into the Death of Corazon Contreras KEELEY

Inquest into the Death of Corazon Contreras KEELEY

Delivered on : 18 October 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 27 July 2020, Corazon Contreras Keeley (Ms Keeley) died from complications of metastatic endometrial carcinoma that was being palliatively treated at Fiona Stanley Hospital, Murdoch (FSH). She was 71 years old.

Pursuant to section 22(2) of the Coroners Act 1996 (WA), the Court determined that a discretionary inquest into Ms Keeley’s death was desirable in order to investigate the standard of medical care and treatment provided to Ms Keeley with respect to her endometrial carcinoma.   

In September 2019, Ms Keeley saw her GP to report post-menopausal bleeding. A pelvic ultrasound ordered by her GP found a thickened endometrium (lining of the womb) and a gynaecologist review was recommended to determine if this was cancer-related.

Ms Keeley’s GP referred her to the gynaecology clinic at Fremantle Hospital. Dr Venkata Kasina was a Consultant Obstetrician and Gynaecologist who worked at Fremantle Hospital and FSH (Dr Kasina). On 29 November 2019, Dr Kasina performed a hysteroscopy dilation and curettage (HDC) procedure on Ms Keeley and samples were taken for histopathology.

On 5 December 2019, the histopathology report identified possible endometrial cancer and that further sampling was necessary for diagnosis. However, instead of recommending another HDC procedure so that further samples could be obtained, Dr Kasina incorrectly advised Ms Keeley and her GP that there were no abnormalities from the histopathology results and that Ms Keeley would be discharged from the care of his gynaecology clinic.

After Ms Keeley continued to present with bleeding to her GP, she was referred again to the gynaecology clinic in early January 2020.

On 19 February 2020, a doctor saw Ms Keeley at the FSH gynaecology clinic. After reviewing the histopathology report and conferring with Dr Kasina, the doctor arranged for a second HDC procedure to be performed by Dr Kasina on 28 February 2020.

The histopathology report from this HDC procedure confirmed that Ms Keeley had a high grade undifferentiated malignancy, i.e. she had a fast progressing cancer.  As with all patients with confirmed gynaecological malignancies, Ms Keeley’s care and treatment was transferred to the gynaecology oncology clinic at King Edward Memorial Hospital (KEMH).     

Despite intensive medical treatment which included chemotherapy and surgery, the rapid progress of Ms Keeley’s uterine cancer rendered it non-survivable. She was transferred from KEMH to FSH on 24 July 2020, and was commenced on end-of-life care. Ms Keely was kept comfortable with palliative medications before she died in the presence of family members three days later.     

The Coroner found there were aspects of Dr Kasina’s care and treatment of Ms Keely that were substandard. These included his failure to give appropriate consideration to an irregular mass that was apparent during the first HDC procedure and his failure to act on the need for another HDC procedure following the first histopathology report. This failure delayed Ms Keeley’s cancer diagnosis by about six to seven weeks.

The Coroner was also critical of the delay by the FSH gynaecology clinic to advise Ms Keely of the cancer diagnosis, and the delay and initial inadequacy of Dr Kasina’s open disclosure to Ms Keeley and her family of his failure to act upon the need for another HDC procedure in a timely manner.      

Notwithstanding Dr Kasina’s errors, the Coroner found that given the aggressive nature of the cancer, it was very unlikely Ms Keeley would have survived had her endometrial carcinoma been diagnosed earlier following the first histopathology report.

Catch Words: Discretionary Inquest - Natural Causes – Failure to Act upon Pathology Recommendations – Open Disclosure Requirements for Clinicians

Last updated: 27-Oct-2023

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