Deceased
Maria Kerr
Demographics
60y, female
Coroner
Coroner Jacqui Hawkins
Date of death
2017-11-30
Finding date
2019-06-07
Cause of death
Pulmonary thromboembolism in a woman recovering from a fractured right ankle
AI-generated summary
Maria Kerr, a 60-year-old woman with obesity and thalassemia minor, died from pulmonary thromboembolism 33 days after sustaining a fractured ankle. An administrative error resulted in her urgent orthopaedic follow-up appointment (scheduled for 31 October) not being booked, delaying her review to 10 November 2017. Although her fracture management was clinically appropriate and would not have changed had she been seen earlier, critical gaps existed: no VTE risk assessment was performed despite significantly reduced mobility, no prophylactic anticoagulation was offered, and no discussion of DVT/PE warning signs occurred. In 2017, no established guideline existed for ED patients with immobilised lower limb injuries being discharged home. The coroner found clinical care appropriate but identified a system-level opportunity for Victorian Emergency Departments to implement VTE risk assessment protocols for discharged patients with reduced mobility, aligning with new 2018 clinical standards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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