Deceased
Ann-Maree Manno
Demographics
57y, female
Coroner
Deputy State Coroner Caitlin English
Date of death
2019-03-30
Finding date
2022-01-20
Cause of death
Pulmonary thromboembolism
AI-generated summary
Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surgery. A haematologist had previously recommended prophylactic enoxaparin for high-risk periods including post-surgery, but this recommendation was not communicated to the surgeon. While in-hospital VTE prophylaxis was provided, she was discharged without chemical prophylaxis or TED stockings despite the surgeon's stated usual practice including TED stockings. The first dose of post-operative heparin was delayed 12 hours. The coroner could not establish that these specific failures directly caused death, but identified systemic gaps: lack of national/state guidelines for VTE prophylaxis in bariatric surgery, communication failures between specialists, and inconsistent application of prophylaxis protocols. The case highlights need for standardized guidelines and better coordination of thromboembolism risk management.
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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53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
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