Deceased
SHANE PETER KERSTJENS
Demographics
42y, male
Coroner
Coroner Dr Jane Hendtlass
Date of death
2007-12-27
Finding date
2011-10-04
Cause of death
Pulmonary thromboembolism and deep calf vein thrombosis
AI-generated summary
Shane Kerstjens, a 42-year-old man with cerebellar dystrophy and intellectual disability, died from pulmonary thromboembolism and deep vein thrombosis. He sustained a tibia and fibula fracture on 6 September 2007, requiring surgical fixation. Although prescribed clexane (low-molecular-weight heparin) for thromboprophylaxis until 4 December 2007, he was transferred to rehabilitation at Bundoora Extended Care Centre on 4 October 2007. He remained largely immobilised during his recovery. On 27 December 2007, he was found unresponsive and could not be revived. The clinical lesson is that patients with significant immobility from lower limb fractures require vigilant thromboprophylaxis monitoring and assessment. Early mobilisation, continued pharmacological prophylaxis beyond discharge, and clinical vigilance for signs of VTE (leg swelling, chest pain, dyspnoea) could potentially have prevented this fatal outcome. Staff at the facility should have been alert to VTE risk given his immobility.
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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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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