Inquest into the death of Kenneth Toll
Deceased
Kenneth Toll
Demographics
male
Date of death
2019-07-20
Finding date
2026-09-22
Cause of death
pulmonary thromboembolism secondary to deep vein thrombosis of the right calf following bilateral knee replacement surgery
AI-generated summary
Kenneth Toll died from pulmonary embolism secondary to deep vein thrombosis on day four after bilateral knee replacement surgery at Albury Wodonga Private Hospital. While the surgery itself was appropriate and well-performed, post-operative management failed critically. The patient developed multiple episodes of supraventricular tachycardia with reduced oxygen saturation—recognized clinical signs of possible pulmonary embolism in post-operative orthopedic patients. The surgeon (Dr K.) failed to recognize this presentation as potentially PE and failed to ensure timely specialist assessment by a cardiologist, despite recognizing arrhythmias. The intended cardiology referral was never properly made or documented. Expert evidence established that timely cardiologist review with empirical anticoagulation initiation may have changed the outcome. The coroner found multiple failures in post-operative care and referred Dr K. to the Medical Council.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to recognize possible pulmonary embolism despite tachycardia and hypoxia
- failure to arrange appropriate cardiology review
- failure to ensure proper referral to cardiologist
- failure to document referrals and consultations
- failure to escalate to specialist care
- delay in specialist assessment
Coroner's recommendations
- Ramsay Health Care to establish policy ensuring medical records clearly identify referrals to other clinicians, including by whom, for what purpose, and with documented outcome
- Referral of Dr K. to Medical Council of New South Wales pursuant to section 151A Health Practitioner Regulation National Law, as evidence may indicate a complaint for unsatisfactory professional conduct and/or lack of competence
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