Deceased
Peter Robin
Demographics
56y, male
Coroner
Decision ofDeputy State Coroner Magistrate Derek Lee
Date of death
2015-10-29
Finding date
2020-02-28
Cause of death
Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary artery atherosclerosis and hypercholesterolaemia as other significant conditions contributing to death
AI-generated summary
Peter Robin, a 56-year-old man with a medical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. He was discharged the same day as planned and died the following day from pulmonary embolism secondary to a deep vein thrombosis in his right calf. Critical clinical lessons include: (1) the importance of coordinated VTE risk assessment—different clinicians reached different risk categories using different tools; (2) inadequate documentation of VTE assessments and prophylaxis; (3) failure of the surgeon to perform direct consultation with the patient's GP regarding his medical history, despite explicit expert recommendation; (4) lack of documented communication between surgical and anaesthetic teams regarding VTE risk. While the mechanical prophylaxis used (TED stockings and sequential compression devices) was appropriate, the absence of clear risk assessment documentation and coordination may have impacted quality assurance and audit capability.
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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