Coronial
SAhospital

Coroner's Finding: STOCK Anthony Douglas

Deceased

Anthony Douglas Stock

Demographics

64y, male

Date of death

2009-12-15

Finding date

2013-08-15

Cause of death

hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperitoneal and pelvic haemorrhage complicating pelvic fractures

AI-generated summary

A 64-year-old man died from hypovolaemic cardiac arrest caused by retroperitoneal bleeding from a pelvic fracture. The bleeding occurred six days post-injury while on high-dose enoxaparin (100mg twice daily) initiated under an orthopaedic protocol. Critical failings included: (1) no blood tests performed after admission to monitor haemoglobin or renal function despite therapeutic anticoagulation; (2) nursing staff ignored patient and family requests for medical review when signs of shock (pallor, clammy skin, diaphoresis) appeared at 3:30-4pm; (3) no doctor assessed the patient between 10:30am and his arrest at 10pm despite multiple requests; (4) the anticoagulation protocol itself was flawed, using full therapeutic rather than prophylactic dosing without clear indication. The coroner found the death was preventable—prompt medical assessment at 4pm would likely have identified shock, triggered investigations and supportive IV therapy, potentially preventing arrest. Key lessons: monitor anticoagulation with regular bloods; respond urgently to family concerns about clinical deterioration; ensure senior review of therapeutic-dose anticoagulation protocols.

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

Specialties

orthopaedic surgeryemergency medicineintensive careanaesthesiaradiology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

enoxaparinmorphineoxycodone

Clinical conditions

pelvic fracturecomminuted acetabular fractureretroperitoneal haemorrhagehypovolaemic shockcardiac arrestarterial bleeding from internal iliac artery branch

Procedures

CT scan of abdomen and pelvisangiographyurinary catheter insertion

Contributing factors

  • high-dose enoxaparin therapy (therapeutic rather than prophylactic dosing)
  • failure to perform serial blood tests to monitor haemoglobin and renal function despite therapeutic anticoagulation
  • failure of nursing staff to respond to patient and family requests for medical assessment when signs of shock appeared
  • no medical review between 10:30am and cardiac arrest despite clinical deterioration
  • movement of bony fracture fragment into pelvic vessels during routine nursing care
  • flawed anticoagulation protocol lacking daily monitoring requirements
  • inadequate supervision of junior doctor implementing anticoagulation protocol
  • failure to escalate clinical concerns to senior medical staff

Coroner's recommendations

  1. The Minister for Health should direct Flinders Medical Centre to carry out enquiries to determine why staff on the afternoon of 12 December 2009 failed to respond to Mr and Mrs Stock's requests that a medical practitioner be summoned
  2. Enquiries should attempt to establish the identity of nursing staff who failed to respond to Mrs Stock's pleas for a doctor to be called; if identified, they should be required to explain why a doctor was not called
  3. Implicit requirement: review and revise anticoagulation protocols for pelvic fractures to use prophylactic rather than therapeutic dosing and explicitly mandate daily blood test monitoring
  4. Implement systems to ensure senior medical review and accountability for anticoagulation protocols
  5. Enhance communication pathways and escalation protocols to ensure family concerns about clinical deterioration are acted upon promptly
Full text
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Source and disclaimer

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.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.