Deceased
RW
Demographics
64y, male
Coroner
Decision ofDeputy State Coroner Kennedy
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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89y · Male·Cervical spine trauma
Robert Driver, 89, died from cervical spine trauma sustained after being struck by another dementia-affected resident in an aged care facility. He was assessed overnight at the facility and transferred to hospital the fo…
0y · Male·Concussive brain injury
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