Deceased
Barbara Anne Deal
Demographics
86y, female
Coroner
Coroner Audrey Jamieson
Date of death
2022-06-29
Finding date
2025-03-28
Cause of death
Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary to recent L4/5 spondylolisthesis lumbar interbody fusion surgery
AI-generated summary
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsistent and unexplained anticoagulation management with medication withheld without documented rationale; inadequate documentation of mechanical prophylaxis; and unclear responsibility for VTE prophylaxis oversight. While the surgeon acknowledged relying on co-managing physicians, neither she nor nursing leadership could explain why apixaban was withheld on day 24 post-op. The coroner found suboptimal VTE prophylaxis administration and missed opportunities for risk re-evaluation, though acknowledged PE can occur despite prophylaxis. Key lesson: clear assignment of responsibility for thromboprophylaxis, adherence to risk assessment protocols, and comprehensive documentation are essential in post-operative care.
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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56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
66y · Male·Intracerebral haemorrhage
A 66-year-old man with intracerebral haemorrhage and concurrent deep vein thrombosis died following an accidental tenfold heparin overdose. The patient received 20,000 units instead of 2,000 units due to a nurse misreadi…
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