Mr P - Non-inquest findings

Contributing factors

• Failure to order requested CTPA despite GP referral requesting urgent PE investigation
• Failure to perform venous doppler ultrasound despite documented calf swelling and PE risk factors
• Anchoring bias on pneumonia diagnosis with failure to revisit differential when clinical findings did not fully explain severity of hypoxia
• Use of prophylactic rather than therapeutic anticoagulation despite high-risk features for PE
• Overconfident dismissal of chronic calf swelling as non-indicative of DVT without investigation
• Lack of formal risk-stratification tools (Wells Score) in ICU assessment
• Assumption by Ayr Hospital that PE had been excluded at Townsville without verification
• Morbid obesity and immobility from recent trauma as significant VTE risk factors

Coroner's recommendations

1. Review of DVT prophylaxis guidelines to determine if evidence-based modifications are required for the obese population
2. Implementation of Australia and New Zealand Best Practice Guidelines 5th Edition for DVT prophylaxis across Townsville Hospital medical departments
3. Establishment of protocols for formal risk-stratification assessment (Wells Score) in ICU patients presenting with respiratory failure
4. Documentation of rationale when overriding referring physician recommendations for urgent imaging such as CTPA
5. Low threshold for performing venous doppler ultrasound and CTPA in high-risk patients despite alternative diagnoses appearing likely
6. Implementation of systematic review procedures when initial diagnosis does not explain clinical findings or trajectory as expected