Coroner's Finding: MYNHART Johann George
Deceased
Johann George Mynhart
Demographics
77y, male
Date of death
2000-05-01
Finding date
2003-01-10
Cause of death
bilateral pulmonary emboli complicating deep vein thrombosis (left calf)
AI-generated summary
A 77-year-old man with dementia died from bilateral pulmonary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On 30 April, his daughter observed classic DVT signs (unilateral leg swelling, calf tenderness, redness, and pitting oedema). Nursing staff documented the oedema but failed to alert medical staff. The duty doctor was not contacted despite clear clinical indicators warranting urgent investigation and anticoagulation. While the DVT likely formed during his hospital stay due to immobility and dehydration, it went undiagnosed at Glenside until too late. The critical failure was nursing staff's decision not to escalate findings to medical staff when classic DVT symptoms were evident and the patient was known to be immobile.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- immobility due to dementia and acute illness
- dehydration
- diabetes mellitus
- failure to escalate DVT signs to medical staff
- nursing staff did not alert doctor to daughter's DVT observations on 30 April
- latent period between DVT formation and fatal embolisation
Coroner's recommendations
- Glenside Acacia Ward nursing staff should be reminded of the need to be vigilant to the possibility of DVT development in patients whose mobility is or has recently been compromised
- Nursing staff should be reminded of the need for urgency in seeking medical intervention if signs or symptoms of DVT are detected
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