A 73-year-old woman admitted with severe respiratory distress was appropriately managed in ICU with intubation and extubated after 8 days. She was transferred to coronary care as stable but deteriorated with cardiorespiratory arrest. Autopsy revealed coronary atherosclerosis as primary cause with contributing anterior abdominal wall haematoma related to anticoagulant therapy. All independent expert review confirmed anticoagulant dosing and medication choices were appropriate and necessary given her severe coronary artery disease and thrombotic risk. The haematoma was difficult to detect clinically and post-mortem analysis confirmed bleeding occurred after transfer from ICU. The coroner found no fault in medical management and concluded risks of anticoagulation were outweighed by benefits in her clinical context.
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Specialties
emergency medicineintensive carecardiologyhaematologyforensic medicine
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