Finding into death of Ronald John Wood
Deceased
Ronald John Wood
Demographics
68y, male
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.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to establish anticoagulation plan post-discharge despite high VTE risk
- lack of coordination between multiple specialists regarding anticoagulation
- silent discharge summaries regarding anticoagulation management
- inadequate communication with general practitioner about anticoagulation plan
- complex medical history with multiple VTE risk factors not synthesised into unified management plan
Coroner's recommendations
- Peninsula Health expand all relevant clinical practice guidelines to require that when patients at risk of VTE are discharged from hospital, both the patient and their general practitioner receive written guidance on anticoagulation, in accordance with Quality Statements 3, 4 and 7 of the Australian Commission on Safety and Quality in Health Care Clinical Care Standard on Venous Thromboembolism Prevention (October 2018)
Full text
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 —