Finding into death of Kathleen Mary Savage
Deceased
Kathleen Mary Savage
Demographics
67y, female
Date of death
2017-11-16
Finding date
2024-03-15
Cause of death
Pulmonary thromboembolism arising from deep vein thrombosis of the left leg
AI-generated summary
Kathleen Mary Savage, a 67-year-old woman with profound intellectual disability, died from pulmonary thromboembolism and deep vein thrombosis following a 13-day hospital admission for constipation and sepsis. She collapsed immediately after discharge. The coroner found that Alexandra District Health failed to assess her for venous thromboembolism risk or prescribe appropriate prophylaxis despite her being largely immobilised in bed for 10 days—a major preventable risk factor. While the coroner could not definitively establish the death was preventable, this represented a clear opportunity for appropriate medical care that was missed. The hospital subsequently implemented comprehensive VTE prevention measures including risk assessment tools, staff education, and compliance monitoring.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to assess for venous thromboembolism risk on admission
- Failure to prescribe venous thromboembolism prophylaxis
- Prolonged bed rest (10 days before physiotherapy assessment)
- Limited understanding by hospital staff of patient's intellectual disability and communication needs
- Delayed mobilisation of patient
Full text
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