Deceased
Bernice Snell
Demographics
74y, female
Coroner
Coroner Katherine Lorenz
Date of death
2022-08-28
Finding date
2023-10-25
Cause of death
Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
AI-generated summary
A 74-year-old woman presented to ED with left leg swelling and calf pain. She was triaged as category 4 and seen by a doctor after a 4-hour 24-minute delay due to staff shortages and access block. A D-Dimer test showed elevation; DVT ultrasound was scheduled for the next morning. Anticoagulation was not administered due to concern about recent gastric ulcer bleeding and recurrent H. pylori. That night she collapsed and died from pulmonary embolism secondary to DVT. The key clinical issues were: significant ED delay in assessment, decision not to anticoagulate despite elevated D-Dimer and moderate DVT probability, and lack of expedited imaging. While anticoagulation was withheld due to genuine bleeding risk, earlier definitive imaging and/or earlier anticoagulation consideration may have altered outcomes.
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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