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Bradshaw, Scott Anthony - Non-inquest findings

Deceased

Scott Anthony Bradshaw

Demographics

38y, male

Date of death

2013-04-29

Finding date

2016-06-20

Cause of death

Pulmonary thromboembolism due to bilateral deep calf vein thrombi

AI-generated summary

A 38-year-old man with schizo-affective disorder, bipolar disorder, and asthma presented to the emergency department with presumed pneumonia based on fever, pleuritic chest pain, and respiratory symptoms. His general practitioner appropriately referred him urgently. The ED team treated him for pneumonia with oxygen and antibiotics. He rapidly deteriorated and died in cardiac arrest. Autopsy revealed pulmonary thromboembolism from bilateral deep vein thrombi as the cause of death, with dilated cardiomyopathy as a contributor. Experts differed on whether pulmonary embolism should have been in the differential diagnosis and whether earlier diagnosis could have prevented death. The clinical diagnosis of pneumonia was reasonable given available clinical data. Had PE been suspected, anticoagulation (not thrombolysis in non-hypotensive patients) might have been considered, but expert opinion diverged on whether this would have changed the outcome. The hospital implemented recommendations including PE education, diagnostic algorithms, and improved airway equipment.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicineintensive carecardiologygeneral practicepathology

Error types

diagnosticcommunication

Drugs involved

hypnodormlithiumclonazepamfluticasone/salmeterolquetiapinetiotropiumsalbutamolketaminefentanylsuxamethoniumadrenalinemetaraminol

Clinical conditions

pulmonary embolismdeep vein thrombosisdilated cardiomyopathypneumonia (presumed working diagnosis)schizoaffective disorderbipolar affective disorderasthmaidiopathic thrombocytopenic purpurapulmonary oedemapulmonary congestioncardiac arrestpulseless electrical activityseptic shock (initially suspected)

Procedures

intubationendotracheal intubationcentral venous line insertionechocardiographycardiopulmonary resuscitationmechanical ventilation

Contributing factors

  • Dilated cardiomyopathy
  • Mild obesity
  • Antipsychotic medication exposure
  • Possible immobility
  • Failure to include pulmonary embolism in differential diagnosis

Coroner's recommendations

  1. Education and awareness campaign to assist clinicians in broadening differential diagnoses and raising suspicion of pulmonary embolism in patients with respiratory distress
  2. Implement a diagnostic algorithm in the Emergency Department for stable and unstable patients suspected of having pulmonary embolism
  3. Increased access to bedside echocardiography
  4. Strengthen the resuscitation team's ability and equipment to manage difficult airways
  5. Consideration of locating CT scanner in the Emergency Department with appropriate resuscitation equipment to improve access and reduce risk of transferring unstable patients
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