Coronial
VICcommunity

Finding into death of Kevin John Harris

Deceased

Kevin John Harris

Demographics

38y, male

Coroner

Coroner Audrey Jamieson

Date of death

2023-01-12

Finding date

2024-12-18

Cause of death

Pulmonary thromboembolism in the setting of deep vein thrombosis

AI-generated summary

Kevin Harris, a 38-year-old man with obesity, sustained a left tibial plateau fracture from a workplace fall on 27 December 2022. His general practitioner managed the injury conservatively with rest, ice, and anti-inflammatory medication, then ordered an MRI after 6 days when pain persisted. The MRI confirmed the fracture, and physiotherapy was recommended. Kevin remained immobilised and non-weight-bearing. On 11 January, his family noted increased knee swelling and shortness of breath. He was found deceased on 12 January. Autopsy revealed pulmonary thromboembolism secondary to deep vein thrombosis, with contributing factors being the fracture, immobilisation, and obesity. The coroner found the GP's management reasonable given the absence of clear clinical guidelines for VTE prophylaxis in general practice settings and Kevin's lack of DVT symptoms during consultations. The coroner recommended RACGP develop clinical guidelines for VTE management in primary care.

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Specialties

general practiceorthopaedic surgerypathology

Error types

system

Clinical conditions

deep vein thrombosispulmonary thromboembolismtibial plateau fractureobesityischemic heart diseaseleft ventricular hypertrophyhepatic steatosischolelithiasis

Procedures

magnetic resonance imaging

Contributing factors

  • left tibial plateau fracture sustained in workplace fall
  • immobilisation and reduced mobility following fracture
  • obesity (WHO Class II)
  • non-weight-bearing status for 16 days
  • absence of VTE prophylaxis

Coroner's recommendations

  1. The Royal Australian College of General Practitioners should consider the creation and publication of a clinical guideline for the diagnosis, prophylaxis and treatment of venous thromboembolism for patients in the general practice setting.
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