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 from pulmonary thromboembolism due to deep vein thrombosis complicating severe pelvic and leg fractures sustained in a motorcycle accident. Following extensive orthopaedic surgery, he was placed on a specialised three-times-daily heparin subcutaneous protocol designed to prevent post-operative thromboembolic disease. A junior doctor, Dr Hassan Hasan, systematically failed to administer correct heparin doses according to the protocol, increasing by 500 units instead of 1000 units on multiple occasions when APTT levels indicated underdosing. Despite protocol familiarity, lack of registrar supervision, and no single registrar assigned to oversee the intern, the errors went undetected for days. While causation could not be established with certainty, therapeutic anticoagulation was never achieved. The case demonstrates critical failures in intern supervision, unclear accountability structures, and inadequate monitoring of complex anticoagulation protocols in hospitals.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…
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 sur…
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