Deceased
Margot Janeece Combes
Demographics
47y, female
Date of death
2017-09-23
Finding date
2020-01-03
Cause of death
pulmonary thromboembolus
AI-generated summary
A 47-year-old nurse suffered a workplace fall resulting in a left ankle fracture requiring below-knee immobilisation. She was managed conservatively with a temporary cast for one week, then a permanent plaster cast applied. Seven days after cast removal, she developed a fatal pulmonary embolism while at home. The coroner found her medical care was of good standard. However, the case highlights the clinical lesson that patients requiring below-knee immobilisation with additional risk factors—particularly morbid obesity—warrant individualised risk assessment for thromboprophylaxis. While anticoagulation debate exists in the literature, high-risk patients may benefit from pharmacologic prophylaxis. The coroner recommended clinicians apply individualised DVT/PE risk assessment in each case of below-knee immobilisation, rather than a one-size-fits-all approach.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Procedures
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: (…
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