Inquest into the death of Sandra McRae

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

1. That system changes proposed by Dr Dianne Stephens be implemented as quickly as possible and supported, particularly by the Orthopaedic Division and its head Mr Sharland
2. That heads of Departments keep abreast of important system changes as and when they occur
3. 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)
4. That the plan in relation to prophylaxis be set out in patient notes so that clinicians reading the notes know what is happening