Finding into death of Carmel Killackey
Deceased
Carmel Killackey
Demographics
77y, female
Date of death
2017-04-20
Finding date
2019-08-05
Cause of death
Pulmonary thromboembolism secondary to deep vein thrombosis of the left leg
AI-generated summary
A 77-year-old woman with Factor V Leiden thrombophilia and history of PE presented to a rural urgent care centre on 19 April 2017 with shortness of breath and chest pain. She was examined by Dr H. who considered but dismissed PE as a diagnosis, attributing symptoms to possible gastrointestinal cause after a diagnostic trial of antacid. She was discharged without ECG, without verification of anticoagulation status (INR test), and without repeat vital signs. She collapsed at home the next day with fatal pulmonary embolism and DVT. Key clinical lessons: PE must be actively considered in patients with thrombophilia presenting with dyspnoea and chest pain; anticoagulation status should be verified by INR testing rather than accepting patient report; ECG is mandatory in chest pain presentations; risk stratification tools should guide investigation; repeat observations before discharge are essential when diagnosis uncertain.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Failure to perform ECG despite chest pain presentation
- Failure to verify anticoagulation status (INR testing) despite patient on warfarin
- Inadequate assessment and failure to exclude PE despite major risk factors (Factor V Leiden, age >60, history of PE/DVT)
- No risk stratification tool (Wells Score or Geneva Score) applied
- Failure to perform appropriate investigations (troponin, chest X-ray, D-dimer, CTPA)
- Reliance on diagnostic trial of antacid without objective investigation
- Discharge without repeat vital signs
- Inadequate medical history documentation regarding PE and differential diagnosis consideration
Coroner's recommendations
- Royal Australian College of General Practitioners and Australian College of Rural and Remote Medicine develop a continued professional development scheme for General Practitioners in Emergency Medicine
- Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine and Australasian College for Emergency Medicine form a tripartite Joint Consultative Committee on Urgent Care and Emergency Medicine to oversee development of Emergency Medicine skills in rural GPs
- Stawell Regional Health continue staff education at its Urgent Care Centre and implement regular audits to ensure policies and procedures are followed
- All patients not requiring admission have a final set of observations completed prior to discharge
- All patients presenting with chest pain must have an ECG; troponins should be considered
- Include section in medication history specifically asking about current warfarin dosing and last INR date and results
- Include additional column in medication history requiring indication for medication to be listed
- Provide opportunities for nursing and medical staff working in Urgent Care Centres to rotate through larger Emergency Departments on semi-regular basis to refresh skills
Full text
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