Deceased
Ronald John Wood
Demographics
68y, male
Coroner
Coroner Darren Bracken
Date of death
2018-04-22
Finding date
2020-05-29
Cause of death
Pulmonary thromboembolus secondary to deep vein thrombosis
AI-generated summary
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to bleeding risk from the cancer and instability during chemotherapy. After surgery, he received appropriate short-term VTE prophylaxis with clexane. However, there was a critical failure to establish an ongoing anticoagulation plan post-discharge despite cumulative VTE risk factors (prior PE, cancer history, major surgery, obesity). Discharge summaries to his GP were silent on anticoagulation management. He died from pulmonary embolism 16 days post-discharge. The hospital's review identified that multiple specialists focused narrowly on their expertise without coordinating overall anticoagulation strategy. Implementation of perioperative physician overview and clear communication protocols to patients and GPs regarding anticoagulation plans could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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58y · Male·complications of large bowel pseudo-obstruction
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