Finding into death of Michael Stankic

Contributing factors

• Suicide attempt by hanging with period of circulatory arrest
• Immobility from mechanical restraint during ICU admission
• Critical illness and intubation
• Prolonged stay in ICU unsuitable for ambulant psychiatric patient due to bed unavailability in psychiatric unit
• Cessation of prophylactic enoxaparin on day 3 (though evidence suggests DVT began before this)
• Early development of DVT despite initial prophylaxis

Coroner's recommendations

1. Provide finding to Australian Commission on Safety and Quality in Health Care for consideration of inclusion of a clear definition of 'immobility' in thromboprophylaxis assessment tools and clinical guidelines, with suggested threshold questions: (1) Is patient at usual level of mobility and function? (2) Is patient spending more than 14 hours per day in bed?
2. Provide finding to Safer Care Victoria for consideration of opportunities to engage with hospitals including Western Health and psychiatric inpatient units on immobility definition for VTE prophylaxis
3. Distribute finding to Thrombosis and Haemostasis Society of Australia and New Zealand, Royal Australian and New Zealand College of Psychiatrists, Royal Australasian College of Physicians, College of Intensive Care Medicine of Australia and New Zealand, Australian Commission on Safety and Quality in Health Care, and Therapeutic Goods Administration for consideration of expansion of guidance on use of direct-acting oral anticoagulants as alternative to low molecular weight heparin thromboprophylaxis in hospital settings where subcutaneous injection cannot be safely administered