Inquest into the death of William Haines
Deceased
William Haines
Demographics
37y, male
Date of death
2021-04-27
Finding date
2023-03-01
Cause of death
Pulmonary thromboembolus due to left leg deep vein thrombosis
AI-generated summary
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessment focused on suspected infective endocarditis, which was appropriately ruled out. However, the coroner found the patient had pulmonary embolism with classic clinical features that should have been investigated. Critical omissions included: failure to provide his significant DVT history (2019, 2015, 2017) to receiving hospitals; absence of VTE risk assessment despite NSW policy requirements; and incomplete diagnostic workup before discharge with a vague 'atypical chest pain' diagnosis. Had PE been diagnosed, anticoagulation could have prevented death. System improvements identified included electronic alert protocols for medical histories, VTE forcing functions in prescribing software, and training initiatives.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Failure to provide previous DVT history to receiving hospital
- Absence of VTE risk assessment despite NSW policy requirements
- Handcuffing to hospital bed limiting mobilisation
- Diagnostic focus on endocarditis obscuring other diagnoses
- Incomplete investigation of undifferentiated symptoms
- Vague discharge diagnosis of atypical chest pain
- No definitive imaging to exclude PE before discharge
- Inadequate follow-up investigation after exclusion of endocarditis
- Limited medical oversight in custodial setting post-discharge
Coroner's recommendations
- Implementation and enforcement of VTE forcing function in MedChart prescribing software across all HNELHD hospitals to require risk assessment before medication prescription
- Improvement of medical history transfer protocols from Justice Health to external hospitals, with automatic population of DVT alerts in transfer documentation
- Implementation of integrated NSW Health records scheme to allow viewing of complete medical histories across agencies
- Ongoing VTE prevention champion programme and training of medical staff at orientation and through professional development
- Regular auditing of VTE risk assessment compliance with feedback to clinical staff
- Review of practices regarding restraint of custodial patients during hospital admission, with consideration of alternatives to bedside handcuffing
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