Non-Inquest findings - DUCHATEL Daniella Jade

Contributing factors

• failure to conduct individual VTE risk assessment at emergency presentation
• failure to document VTE risk assessment at fracture clinic despite risk factors being present
• inadequate assessment of patient motivation and capacity to comply with mobility recommendations
• failure to prescribe prophylactic blood-thinning medication pre-operatively despite strong indication
• lack of clear patient education about VTE risks and importance of compliance
• possible premature cessation of aspirin prophylaxis three days before death
• obesity (BMI >30)
• oral contraceptive use
• active vaping
• prolonged leg immobilization with Richard splint
• reduced mobility post-discharge
• underlying coronary atherosclerosis with 70% left anterior descending artery occlusion

Coroner's recommendations

1. Royal Brisbane and Women's Hospital to review current processes around application and documentation of the QH Guideline for patients presenting with traumatic orthopaedic injuries
2. Provide clear definition and clarification of what constitutes lower limb immobilisation and rigid immobilisation
3. Articulate differences between below-knee rigid cast and semi-rigid knee splint and VTE prophylaxis requirements
4. Provide information and guidance about specific considerations for primary prophylaxis
5. Emphasise the 'encourage mobilisation' section in ambulatory and orthopaedic sections of guideline
6. Incorporate reassessment of VTE risk in line with QH Guideline recommendations
7. Provide information and education about VTE risks and risk reduction plans for each patient
8. Ensure VTE risk assessments are documented at the time in places easily accessible to all clinicians
9. Provide feedback and in-service training to emergency centre, orthopaedic fracture clinic and preadmission clinic staff
10. Develop and implement clear VTE prophylaxis guideline with straightforward risk algorithm for lower limb injuries
11. Recommend low molecular weight heparin rather than aspirin for patients at high VTE risk
12. Create clear and concise visual 'Stop the Clot' factsheets and video tools for clinicians and patients
13. Clarify ambiguities in QH Guideline descriptions with Statewide Anticoagulant Working Party
14. Improve consistency of VTE risk assessment and prophylaxis guidance throughout Metro North Health
15. Review Patient Risk Assessment form to ensure compliance with contemporary VTE risk assessment processes
16. Develop improved consumer education resources for VTE prophylaxis and risk reduction
17. Plan for integration of digital VTE risk assessment forms into electronic medical record system