Coronial
NSWhospital

Inquest into death of RW

Deceased

RW

Demographics

64y, male

Date of death

2021-01-07

Finding date

2022-12-01

Cause of death

Pulmonary thromboembolus as a result of bilateral deep vein thrombosis which developed after treatment for a self-inflicted intentional motorcycle collision, on the background of chronic ischaemic heart disease

AI-generated summary

RW, a 64-year-old with chronic ischaemic heart disease, suffered traumatic brain injury from an intentional motorcycle collision and underwent emergency neurosurgery. He was subsequently treated with unfractionated heparin twice daily for DVT prophylaxis. At day 34 post-injury, while clinically improving and awaiting rehabilitation, he collapsed and died from bilateral DVT-associated pulmonary embolus. The coroner found his treatment was in accordance with accepted medical practice. A key clinical lesson involves the tension between DVT prophylaxis and bleeding risk in traumatic brain injury patients receiving anticoagulation. Guidelines have since evolved to consider enoxaparin after day 3 when bleeding risk decreases, though neurosurgeons favour reversible heparin. Communication with family regarding DVT risk and proper mechanical prophylaxis (compression stocking fit and usage) could have been improved, though these would not have changed the outcome.

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

Specialties

neurosurgeryintensive carehaematologytrauma surgery

Error types

communicationprocedural

Drugs involved

unfractionated heparindexmedetomidine

Clinical conditions

traumatic brain injuryintracranial haemorrhagesubarachnoid haemorrhagediffuse axonal injurydeep vein thrombosispulmonary embolismchronic ischaemic heart diseasevenous thromboembolismfacial and orbital fractureschest trauma

Procedures

emergency neurosurgery for intracranial pressure reliefexternal ventricular drain insertion and removalendotracheal intubation and extubation

Contributing factors

  • Traumatic brain injury requiring neurosurgery
  • Period of immobility and ICU admission
  • Chronic ischaemic heart disease
  • Risk-benefit balance between DVT prophylaxis and intracranial bleeding risk leading to continued use of unfractionated heparin
  • Possible suboptimal mechanical prophylaxis (compression stocking fit and compliance issues)
  • Limited specialist review between 29 December 2020 and 7 January 2021
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