Deceased
Makushla Nikolaevsky
Demographics
43y, female
Coroner
Decision ofDeputy State Coroner Forbes
Date of death
2017-07-07
Finding date
2020-11-27
Cause of death
pulmonary embolism
AI-generated summary
A 43-year-old woman died from pulmonary embolism after hysteroscopy for investigation of heavy menstrual bleeding. Following the procedure, she developed left leg swelling on day 3. A Venous Doppler Ultrasound was performed but did not extend above the inguinal ligament. She was reassured after negative imaging and the intrauterine balloons were removed. She collapsed the next morning with massive bilateral pulmonary embolism. Coroner found the failure to scan above the inguinal ligament was not unreasonable given the rare clinical presentation, though vascular surgeons believed extended imaging should have been performed to exclude iliofemoral thrombosis. The prescribing decisions (reduced Clexane dose and tranexamic acid) were considered reasonable given the competing risks of heavy bleeding versus thrombosis. No systemic recommendations were made due to the exceptional rarity of the case.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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