Inquest into the death of Sandra McRae
Deceased
Sandra McRae
Demographics
57y, female
Date of death
2005-03-13
Finding date
2008-10-29
Cause of death
acute pulmonary embolism
AI-generated summary
Sandra McRae, age 57, died from pulmonary embolism on day 13 of hospitalisation following pelvic fractures sustained in a motor vehicle accident. The coroner found the death was potentially preventable due to failure to administer thromboprophylaxis despite hospital guidelines clearly indicating its use in moderate-risk trauma patients. Key failures included: (1) inadequate documentation of clinical decisions regarding thromboprophylaxis; (2) insufficient physical mobilisation to justify withholding prophylaxis; (3) lack of formal handover between orthopaedic teams when consultant Robin Cripps was unexpectedly absent; (4) failure to follow existing RDH thromboembolism prophylaxis guidelines; and (5) poor note-taking making decisions unintelligible to subsequent clinicians. While no guarantee existed that prophylaxis would have prevented death, the coroner found anticoagulation should have been administered once haemodynamic stability and absence of bleeding were confirmed. The hospital acknowledged this was a sentinel event and implemented significant reforms in documentation, guideline compliance, and handover protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to administer thromboprophylaxis despite hospital guidelines
- inadequate documentation of clinical decision-making
- insufficient mobilisation to justify withholding prophylaxis
- lack of formal handover between orthopaedic teams
- unexplained absence of primary consultant Robin Cripps
- failure to follow RDH thromboembolism prophylaxis guidelines
- poor quality clinical note-taking
- failure to assess and document risk factors
- lack of continuity of care
Coroner's recommendations
- That system changes proposed by Dr S. be implemented as quickly as possible and supported, particularly by the Orthopaedic Division and its head Mr Sharland
- That heads of Departments keep abreast of important system changes as and when they occur
- That a recommendation be made to all Northern Territory hospitals similar to that made by Jonathan Rush to Victorian hospital CEOs: for each patient admitted a decision about the type of prophylaxis should be made and noted in the medical record with consideration of the patient's age, the nature of the operative procedure and/or treatment, and the presence of identified risk factors (including 'nil required' where applicable)
- That the plan in relation to prophylaxis be set out in patient notes so that clinicians reading the notes know what is happening
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