Finding into death of Andrew Michael ODonnell
Deceased
Andrew Michael O'Donnell
Demographics
46y, male
Date of death
2012-12-26
Finding date
2016-10-25
Cause of death
Pulmonary thromboembolism complicating left calf deep venous thrombosis
AI-generated summary
A 46-year-old man presented to ED with a two-day history of left calf pain, swelling and numbness. He was triaged to Fast Track and evaluated by an emergency physician who suspected DVT but had no ultrasound available on Boxing Day. He was discharged with Clexane and a follow-up ultrasound appointment. That evening at home he collapsed and died from a saddle pulmonary embolism. The coroner found the triage assessment was appropriate, Fast Track referral was justified, and the decision to discharge with anticoagulation was consistent with accepted practice. The clinical significance of triage notation of 'slight SOB' was unclear; the physician found no evidence of pulmonary embolism at assessment. The coroner determined that admission to hospital would not have altered the outcome given the massive nature of the PE. However, she noted the patient received no written discharge information about DVT warning signs, which the hospital subsequently remedied.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Undiagnosed pulmonary embolism at time of discharge
- Lack of CT pulmonary angiogram despite presentation with DVT
- Absence of written discharge information about DVT warning signs
- Boxing Day presentation with limited ultrasound availability
- Unclear clinical assessment regarding severity of shortness of breath at triage
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