Deceased
Carlene Margaret Salveson
Demographics
80y, female
Coroner
Coroner Audrey Jamieson
Date of death
2018-11-14
Finding date
2021-06-10
Cause of death
pulmonary thromboembolism in the setting of deep leg vein thrombosis; squamous cell carcinoma of the left pyriform fossa (treated)
AI-generated summary
An 80-year-old woman with treated squamous cell carcinoma of the pyriform fossa died from pulmonary thromboembolism secondary to bilateral deep vein thrombosis. She was admitted to hospital with poor oral intake, dehydration, and acute kidney injury following chemotherapy and radiotherapy. Critical risk factors for venous thromboembolism were present: age, cancer, dehydration, immobility, and hospitalisation. Alfred Health failed to prescribe pharmacological DVT prophylaxis despite having a management plan requiring it. The failure was attributed to implementation of a new Electronic Medical Record system on the ward which lacked appropriate decision-support alerts for VTE prophylaxis at go-live. Compliance with VTE prophylaxis dropped post-implementation. The coroner found this represented a missed opportunity to intervene, though could not definitively establish preventability. System failures in EMR implementation rather than individual clinician error were the primary contributing factor.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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