Coronial
VIChospital

Finding into death of Anna Agnieszka Bowditch

Deceased

Anna Agnieszka Bowditch

Demographics

34y, female

Date of death

2014-08-21

Finding date

2018-12-03

Cause of death

Complications of fall with fractured ankle and subsequent deep venous thrombosis with embolisation

AI-generated summary

Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobility from leg casting, recent long-haul flight, oral contraceptive use, and borderline obesity. The coroner found that orthopaedic surgeon Mr Widjaja's pre-operative examination of her leg was inadequate—he examined through the bandage and back-slab rather than removing them for full visualisation and palpation, a five-minute procedure. The expert panel unanimously agreed this examination was insufficient to detect possible DVT and inconsistent with good practice. Although no documented signs or symptoms of DVT were recorded pre-operatively, and risk factors alone do not mandate investigation, a fuller examination might have identified concerning signs. An undiagnosed patent foramen ovale allowed paradoxical embolism to the brain. While the death was causally related to surgery, it was deemed not preventable on balance of probabilities, as DVT could have occurred regardless with similar fatal consequences.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

orthopaedic surgeryanaesthesianeurosurgeryintensive carevascular surgery

Error types

proceduraldiagnostic

Drugs involved

clonazepamsertralinebrenda-35 ednaproxenhydrocodone

Clinical conditions

deep venous thrombosispulmonary embolismischaemic strokepatent foramen ovalefibular fracturevenous thromboembolismparadoxical embolism

Procedures

fracture repair surgerygeneral anaesthesiaendovascular thrombus retrievalinferior vena cava filter placement

Contributing factors

  • Inadequate pre-operative physical examination of fractured limb by orthopaedic surgeon
  • Examination conducted through bandage and back-slab without removal
  • Multiple known DVT risk factors not adequately weighted in risk assessment
  • Undiagnosed patent foramen ovale enabling paradoxical embolism
  • Immobility from fracture and casting
  • Recent long-haul flight
  • Oral contraceptive use
  • Borderline obesity

Coroner's recommendations

  1. The Royal Australasian College of Surgeons should use the circumstances of Anna Bowditch's death to create a learning tool for orthopaedic surgeons on how to conduct fulsome and rigorous physical examination of a fractured limb
Full text
Official source Archived copy

Related cases

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —