Channell & ivanoska decision
Deceased
Jennifer Channell and Helen Ivanoska
Demographics
female
Date of death
2005-04-18 and 2011-07-18
Finding date
2012-11-20
Cause of death
Pulmonary thromboembolism due to deep vein thrombosis following lower leg fracture
AI-generated summary
Two women aged 48 and 59 presented to Shellharbour Hospital ED with lower leg fractures sustained in falls. Both were treated conservatively with immobilization (splint and plaster back slab) and discharged home without assessment for venous thromboembolism risk or prophylaxis, despite multiple VTE risk factors: marked obesity (BMI 43.4 and 37.4), immobility from immobilization, age, and in one case possible lupus and previous varicose veins. Both died at home within days from fatal pulmonary embolism secondary to deep vein thrombosis. Expert witnesses unanimously agreed both should have received VTE risk assessment and pharmacological prophylaxis (low-molecular-weight heparin). The treating doctors failed to consider VTE at all; subsequent statements contradicted inquest testimony. A critical system gap was identified: VTE guidelines applied only to admitted inpatients, not ED discharges, despite identical risk profiles. The coroner found the deaths represented a 'missed opportunity' where both patients were denied potential benefit of prophylaxis. Recommendations include ED guidelines for VTE assessment in leg fracture patients, routine BMI recording, and education on clinical judgment independent of protocol.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Failure to assess or consider VTE risk
- Absence of VTE guidelines/protocols for ED patients
- Marked obesity (BMI 43.4 and 37.4)
- Immobility from leg immobilization (splint and plaster back slab)
- Age (48 and 59 years)
- Lower leg fractures requiring immobilization
- No pharmacological VTE prophylaxis offered or provided
- In Ivanoska: possible lupus diagnosis, previous varicose veins
Coroner's recommendations
- Creation of a Guideline/Policy addressing the need for patients with lower leg fractures treated in the Emergency Department to be assessed and if appropriate treated for the risk of Venous Thromboembolism (VTE)
- Determination of the most appropriate manner by which a patient's Body Mass Index can be recorded as part of any VTE risk assessment process
- Development of an education program to remind medical staff that treatment should be designed to meet the clinical needs of a patient regardless of whether specific Policies or Guidelines are in place
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