Coronial
SAhospital

Coroner's Finding: MURRAY John Matthew

Deceased

John Matthew Murray

Demographics

35y, male

Date of death

2002-10-17

Finding date

2005-10-13

Cause of death

pulmonary thromboembolism due to left deep calf vein thrombosis complicating left lower leg and pelvic fractures

AI-generated summary

John Matthew Murray, aged 35, died of pulmonary thromboembolism complicating pelvic and leg fractures sustained in a motorcycle accident. He was admitted to Royal Adelaide Hospital and underwent extensive orthopaedic surgery. Post-operatively, he was prescribed a specialized heparin anti-thrombotic regime designed to prevent thromboembolic disease. The intern responsible for his care, Dr Hassan Hasan, repeatedly failed to prescribe correct heparin doses according to protocol, increasing doses by 500 units when 1000 units were required on multiple occasions. While the coroner could not definitively establish that this dosing error caused death, the protocol was never achieved at therapeutic anticoagulant levels. Contributing systemic failures included inadequate supervision of the intern by registrars, lack of clear accountability for intern supervision, and no timely detection of prescription errors. Key lessons: specialized protocols require mandatory initial supervision; registrar accountability for specific interns must be explicit; errors in dose escalation should be detected by multiple oversight mechanisms.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

orthopaedic surgerytrauma surgeryhaematologygeneral medicine

Error types

medicationsupervisionsystem

Drugs involved

heparinwarfarin

Clinical conditions

pulmonary embolismdeep vein thrombosispelvic fractureleft tibia fracturethromboembolic disease

Procedures

pelvic fracture reduction and stabilizationtibial fracture fixation with external fixatorwrist fracture reductionfoot laceration debridement and suturing

Contributing factors

  • failure to prescribe correct heparin doses according to protocol
  • inadequate supervision of intern by registrars
  • lack of clear accountability for intern supervision within unit structure
  • failure to detect prescription errors despite multiple oversight opportunities
  • initial period (1-6 October 2002) without anticoagulation coverage due to bleeding risk post-surgery
  • heparin never achieved therapeutic anticoagulant effect at APTT stable range of 28.5-33

Coroner's recommendations

  1. Department of Health to advise surgeons to proactively contact the Forensic Science Centre to obtain post-mortem findings rather than waiting for results to be conveyed to them
  2. Royal Adelaide Hospital to conduct a review of orthopaedic unit structure with a view to improving registrar supervision of interns and requiring that responsibility and accountability for a particular intern be reposed in a designated registrar
  3. Medical Board of South Australia to consider these findings regarding registration of overseas trained doctors, with particular attention to screening and early-stage supervision of doctors trained in countries with limited interaction with Australian medical community
Full text
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This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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