Deceased
Antonios Myrianthopoulos
Demographics
76y, male
Coroner
Coroner Katherine Lorenz
Date of death
2022-01-25
Finding date
2024-03-20
Cause of death
pulmonary thromboembolism in the setting of deep vein thrombosis
AI-generated summary
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleeding, and enoxaparin was prescribed as VTE prophylaxis during admission. At discharge, the decision to recommence anticoagulation was deferred to the GP rather than being managed by the specialist team. Critically, VTE prophylaxis was not continued post-discharge despite therapeutic anticoagulation being interrupted. The patient died from pulmonary embolism 3 days after discharge. The coroner found the death preventable, identifying failures in anticoagulation management, lack of GP communication, absence of discharge documentation, and failure to continue post-discharge VTE prophylaxis. Key lessons: complex anticoagulation decisions should remain with specialist teams, discharge VTE prophylaxis must continue when therapeutic anticoagulation is interrupted, clear communication with primary care and patients is essential, and written discharge advice should always be provided.
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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50y · Male·unascertained
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