Finding into death of Mary Veronica Morrow
Deceased
Mary Veronica Morrow
Demographics
68y, female
Date of death
2021-07-06
Finding date
2023-10-10
Cause of death
Pulmonary embolism due to deep venous thrombosis secondary to fractured left distal tibia and fibula
AI-generated summary
Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but this was not maintained after discharge from Albury Wodonga Health ED on 26 June 2021, despite multiple surgical cancellations over 10 days. No documented process existed to manage VTE risk in patients awaiting urgent surgery in the community. The coroner found her death was preventable had the National VTE Prevention Standard been consistently followed. Clinical lessons: maintain VTE prophylaxis in immobilised patients awaiting surgery; implement clear communication systems for patients discharged pending procedures; use structured risk assessment tools; document clinical decisions explicitly.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Cessation of VTE prophylaxis (enoxaparin) after discharge from ED despite immobilisation
- Multiple surgical cancellations (6 total) over 10-day period
- Inadequate documentation regarding ongoing management and communication with patient
- No documented process to oversee management of clinical risks for patients awaiting urgent theatre at home
- Lack of communication between orthopaedic team and Access and Flow unit regarding bed availability
- Absence of state-based Victorian guideline for VTE prophylaxis in discharged ED patients with reduced mobility
- No clear responsibility assigned to any clinician for VTE management during this period
- Emergency Theatre Booking System (ETBS) did not flag multiple cancellations or provide running tally of waiting days
- Immobilisation from ankle fracture
- Obesity identified as additional risk factor
Coroner's recommendations
- Safer Care Victoria to finalise and publish a Victorian guideline on VTE risk management of patients discharged from Emergency Department with significantly reduced mobility, having regard to the Australian Commission on Safety and Quality in Healthcare: Venous Thromboembolism Prevention Clinical Care Standard (October 2018) and other state-based guidelines
- Albury Wodonga Health to continue regularly reviewing its system of VTE prevention to ensure compliance with applicable standards, including the newly-released Victorian Guideline for the Prevention of Venous Thromboembolism (VTE) in Adult Hospitalised Patients
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