Finding into death of Kathleen Raven
Deceased
KATHLEEN RAVEN
Demographics
85y, female
Date of death
2012-01-26
Finding date
2012
Cause of death
Pulmonary embolus secondary to deep vein thrombosis, precipitated by minor fall
AI-generated summary
An 85-year-old woman died from pulmonary embolism secondary to deep vein thrombosis following a minor fall. She was admitted to Maryborough Hospital with chest infection and abdominal pain. Despite being identified as high VTE risk, thromboprophylaxis was not prescribed due to incorrect application of the VTE risk assessment form and poor communication between nursing and medical staff. The form documentation suggested ambulation and aspirin precluded prophylaxis, which was incorrect. Although the Visiting Medical Officer stated he would have been unlikely to prescribe prophylaxis based on comorbidities, the clinical lesson is that VTE risk assessment tools require proper education, correct interpretation, and explicit medical decision-making documentation. System improvements including dedicated medication chart sections and auditing processes were subsequently implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to implement venous thromboembolism prophylaxis despite high VTE risk
- Incorrect application of VTE risk assessment form by nursing staff
- Poor communication between nursing and medical staff regarding VTE assessment
- Advanced age and immobility
- Recent chest infection
- Minor falls with potential for immobilization
- Absence of explicit medical decision-making documentation regarding VTE prophylaxis
Coroner's recommendations
- Education be provided to Maryborough Hospital medical and nursing staff regarding venous thromboembolism risk factors (including advanced age, chest infection, polycythaemia rubra vera, immobilization, chronic heart disease, hypertension, previous DVT and hospital admission within the past three months) and appropriate VTE prophylaxis management consistent with Maryborough Hospital VTE Risk Assessment Form 147C and NCIS Guidelines
- Internal auditing and ongoing education of the application of Maryborough Hospital Form 147C to ensure nursing staff appropriately refer all moderate to high VTE risk patients for review by the treating Visiting Medical Officer
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