Finding into death of Shane Peter Kerstjens
Deceased
Shane Peter Kerstjens
Demographics
42y, male
Date of death
2007-12-27
Finding date
2011-10-04
Cause of death
Pulmonary thromboembolism secondary to deep vein thrombosis
AI-generated summary
Shane Peter Kerstjens, a 42-year-old man with cerebellar dystrophy and intellectual disability, fell at home on 6 September 2007, sustaining fractured tibia and fibula requiring surgical fixation. Following surgery, he received clexane anticoagulant prophylaxis until 4 December and was transferred to Bundoora Extended Care Centre for rehabilitation. On 27 December 2007, he was found unresponsive and died; autopsy confirmed pulmonary embolism secondary to deep vein thrombosis. The coroner concluded death resulted from undiagnosed thromboembolism without specific recommendations. This case illustrates the diagnostic challenge of VTE in immobilized post-operative patients and highlights the importance of ongoing thromboembolism risk assessment during rehabilitation. The discontinuation of prophylaxis on 4 December—approximately three weeks before death—raises questions about appropriate VTE prophylaxis duration in this patient population.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Drugs involved
Clinical conditions
Contributing factors
- Fall on 6 September 2007 resulting in fractured tibia and fibula
- Post-operative immobilization and reduced mobility
- Surgical intervention and anaesthesia
- Discontinuation of clexane prophylaxis on 4 December 2007
- Undiagnosed venous thromboembolism
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