Deceased
Katica Jovanovic
Demographics
46y, female
Date of death
2002-01-14
Finding date
2004-07-15
Cause of death
pulmonary thromboembolism due to bilateral deep calf vein thrombosis
AI-generated summary
A 46-year-old woman with schizo-affective disorder died from pulmonary thromboembolism secondary to bilateral deep vein thrombosis five days after involuntary psychiatric admission. She was severely withdrawn, refusing food, fluids, and mobilisation due to her acute psychotic illness. Staff recognised DVT risks and encouraged mobilisation, but comprehensive physical examination was hindered by her resistance. Elevated temperature and tachycardia on day 2-3 of admission were not vigorously investigated for sepsis or other complications. Clinical lessons include: pursuing comprehensive physical assessment despite patient resistance; investigating unexplained vital sign abnormalities; earlier consideration of VTE prophylaxis in immobilised psychiatric patients; and documenting absent findings, not just impressions, during physical examination attempts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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