Finding into death of Frank Day
Deceased
Frank Day
Demographics
60y, male
Date of death
2013-11-16
Finding date
2015-08-26
Cause of death
Pulmonary thromboembolism in a man with deep vein thrombosis following a fractured ankle sustained in a motorcycle incident
AI-generated summary
A 60-year-old man with obesity, hypertension, and dyslipidemia sustained a fractured right ankle in a motorcycle collision. He presented to ED with chest pain on 3 November but was diagnosed with musculoskeletal pain; ECG and troponin were normal. He attended orthopaedic follow-up on 6 and 13 November where healing was noted. The patient and his partner reported a cold foot after discharge and calf pain post-fracture but did not seek medical advice, believing these were normal. He died on 16 November from pulmonary embolism secondary to DVT. The coroner found medical care reasonable but noted that patients with lower limb fractures requiring immobilisation were not provided written information about DVT/PE signs and symptoms. This represents a gap in patient education rather than clinical mismanagement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Recent ankle fracture with immobility
- Obesity (BMI 33)
- Lack of thromboprophylaxis
- Absence of written patient information regarding DVT/PE signs and symptoms
- Patient and carer did not recognise warning signs (cold foot, calf pain) as potentially serious
Coroner's recommendations
- That the Department of Health and Human Services consider the need for hospital Emergency Departments to provide written information regarding the risk and symptoms of deep vein thrombosis and pulmonary embolism to patients who present with lower limb injuries requiring immobilisation, particularly if they have additional risk factors.
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