Deceased
Jason Mark Brook
Demographics
45y, male
Date of death
2014-11-07
Finding date
2016-08-26
Cause of death
massive pulmonary embolism due to deep vein thrombosis of the left leg
AI-generated summary
A 45-year-old man died of massive pulmonary embolism secondary to deep vein thrombosis, 15 days after a motorcycle injury in Thailand requiring surgical wound management and foot fracture immobilization. He was discharged with the fracture in a plaster cast but did not receive prophylactic anticoagulation therapy. The coroner found he was at high risk for DVT (lower limb fracture, infection, prolonged immobilization) and should have received anticoagulation throughout his immobilized period, both in hospital and post-discharge. A medical consultant concluded that anticoagulation would have significantly reduced DVT risk and likely prevented his death. Multiple system failures were identified: the surgeon's ambiguous post-operative instruction ('clexane tonight'), junior doctor misinterpretation (single dose instead of ongoing), no anticoagulation prescribed at discharge, and senior clinicians failing to notice the omission on ward rounds. The hospital acknowledged the failure, undertook root cause analysis, and committed to VTE protocol education and audit.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
44y · Female·Pulmonary thromboembolism complicating a fractured left ankle (not operated), su…
A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —