Saddle pulmonary embolus as a consequence of deep venous thrombosis in the right calf, associated with multiple previous surgery of the right leg
AI-generated summary
Glen Malcolm Klose, aged 71, died from a saddle pulmonary embolus secondary to deep vein thrombosis in his right calf, a complication associated with his history of multiple knee surgeries. He was admitted to Glenside Hospital on 14 July 2000 under Mental Health Act detention for severe depression with psychotic features. On 28 July 2000, he was transferred to Royal Adelaide Hospital where right calf DVT was identified on ultrasound but no anticoagulation was administered. He collapsed in cardiac arrest the following morning. The coroner found the death unrelated to his detention or hospital care. A procedural issue was identified regarding the grant of leave of absence rather than formal transfer under the Mental Health Act, which created ambiguity about his legal status during hospitalisation.
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Specialties
psychiatrygeneral medicineintensive care
Error types
delay
Clinical conditions
deep venous thrombosispulmonary embolismdepressionpsychotic features
Contributing factors
History of multiple knee surgeries on right leg
Deep vein thrombosis in right calf identified but not treated with anticoagulation
Procedural ambiguity regarding Mental Health Act leave of absence versus formal transfer
Coroner's recommendations
Prefer formal transfer of detained patients under Section 16 of the Mental Health Act rather than granting leave of absence, unless it is clear the patient has recovered from the condition for which they were detained
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