Coronial
VIChospital

Finding into death of Eoghan Jerome Arnold

Deceased

Eoghan Jerome Arnold

Demographics

42y, male

Date of death

2018-11-16

Finding date

2020-11-25

Cause of death

Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pulmonary embolism, arising from deep venous thrombosis post tibial fracture in motor vehicle accident

AI-generated summary

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He developed a deep venous thrombosis despite receiving standard prophylaxis with enoxaparin 40mg daily and TED stockings. The PE occurred intraoperatively during planned definitive fixation surgery 11 days post-injury. The coroner found the medical care provided at both Royal Melbourne Hospital and Brunswick Private Hospital was appropriate and timely. Standard DVT prophylaxis was given, though enoxaparin was withheld the night before surgery (later identified as not required by unit protocol for non-major pelvic/spinal surgery). The coroner emphasised the significant burden of venous thromboembolism in hospitalised patients and the lack of a consensus Australian guideline, recommending development of a Victorian evidence-based guideline.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

orthopaedic surgeryanaesthesiarehabilitation medicinecardiothoracic surgeryintensive care

Error types

system

Drugs involved

enoxaparinparacetamoloxycodone/naloxonegabapentinoxycodoneadrenaline

Clinical conditions

deep venous thrombosispulmonary embolismtibial plateau fracturecardiac arrestanaphylaxis (initially suspected)obesity

Procedures

external fixation of tibial fracturewound debridementopen reduction and internal fixation of tibial fracturetransoesophageal echocardiographypulmonary embolectomyextracorporeal membrane oxygenation (ECMO)electroencephalographyfour-vessel angiogram

Contributing factors

  • Deep venous thrombosis post tibial fracture
  • Reduced mobility due to external fixation
  • Obesity (BMI 46.7)
  • Recent orthopaedic surgery
  • Withholding of enoxaparin the night before surgery
  • 11-day interval between initial fracture and definitive fixation surgery

Coroner's recommendations

  1. Safer Care Victoria should develop an evidence-based guideline for venous thromboembolism prophylaxis consistent with the Queensland Health guideline. The guideline could be incorporated into a local standard care pathway to ensure that appropriate consideration of VTE prophylaxis is given to all patients according to their level of risk.
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