Finding into death of Darren Templeton

Contributing factors

• VTE risk assessment form not completed on admission
• VTE risk assessment section on medication chart not completed
• absence of formal pre-operative VTE assessment by orthopaedic surgeon
• inadequate pharmacological VTE prophylaxis (aspirin monotherapy only)
• no pharmacological prophylaxis despite high-risk status
• high-risk patient factors not formally documented (obesity BMI 31.5, major orthopaedic surgery)
• post-discharge breathlessness symptoms reported but not investigated
• patient did not seek medical review for breathing difficulties after discharge
• deviation from hospital VTE prevention policy by treating surgeon

Coroner's recommendations

1. St Vincent's Private Hospital RCA should review their VTE prevention policy and consult orthopaedic surgeons to reach consensus and address wide variations in VTE prophylaxis practices
2. St Vincent's Private Hospital should ensure completion of VTE prevention policy review in a timely manner with specific completion timeframe established
3. St Vincent's Private Hospital VTE Prevention Policy should be updated to improve staff adherence to completion and documentation of VTE risk assessment in all hospitalised patients; prescribed management should be clearly documented and supported by evidence-based guidelines; increase staff education on VTE risks in the interim
4. Victorian Department of Health and Human Services should consider public education campaign to raise awareness of VTE risk and importance of early mobilisation, particularly in people with BMI over 30 who are immobilised or recently discharged from hospital