Coronial
NSWhospital

Inquest into the death of Stephen Kline

Deceased

Stephen Kline

Demographics

51y, male

Date of death

2016-03-15

Finding date

2019-03-01

Cause of death

Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg burn wound

AI-generated summary

Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. His expected brief hospital stay extended to 7 days after he swallowed keys (intentional self-harm). Clinical lessons: (1) VTE risk assessment and pharmacological prophylaxis should be reconsidered when anticipated discharge is extended unexpectedly; (2) electronic medical records must clearly display medication cancellations alongside active medications to prevent prescribing errors; (3) elevated heart rate trends in hospitalised patients warrant escalation for medical review even when non-specific symptoms predominate; (4) clinical staff need education on VTE assessment in context of prolonged, unplanned admissions.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

plastic and reconstructive surgerypsychiatrycardiologyintensive careradiologyanaesthesia

Error types

diagnosticsystemdelay

Drugs involved

heparindiazepamthiamineoc spray

Clinical conditions

deep vein thrombosispulmonary embolismburn wound (5% total body surface area, partial thickness to left leg)venous thromboembolismdeliberate self-harm

Procedures

TASER deploymentburn wound scrubbing and debridementbiobrane xenograft applicationCT scan of abdomen and pelvisx-ray abdomen (serial)

Contributing factors

  • Unexpected extension of hospital admission due to swallowed keys requiring passage monitoring
  • Immobility and bed rest for extended period
  • Leg burn wound creating DVT risk
  • Failure to prescribe venous thromboembolism prophylaxis after admission was extended
  • Dr S.'s mistaken belief that heparin had been charted due to electronic medical record display limitations
  • Elevated heart rate (trending upwards to just below 120 bpm) on 13-14 March not escalated for medical review
  • Limited clinical reassessment once admission duration unexpectedly extended
  • Lack of mandatory VTE risk assessment tool usage
  • No communication that final CT report was urgent, delaying radiologist review

Coroner's recommendations

  1. Copy findings to developer of eMeds software system for consideration in Recommendation 2
  2. In consultation with NSW Ministry of Health, request eMeds software developer ensure users can readily distinguish between actively administered medication and cancelled medication, irrespective of on-screen display chosen, without detracting from functionality and usability
  3. Consider using Stephen's case (with anonymisation and family consent) as case study in education packages for clinical staff regarding VTE risk assessment in context of unexpected extension of patient admission duration
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