Finding into death of Robert John Robinson
Deceased
Robert John Robinson
Demographics
74y, male
Date of death
2024-07-11
Finding date
2025-09-17
Cause of death
Pulmonary thromboembolism in the setting of deep leg vein thrombosis
AI-generated summary
A 74-year-old man died from pulmonary thromboembolism with deep vein thrombosis 10 days after elective umbilical hernia repair. He received appropriate VTE prophylaxis (mechanical and pharmacological) intraoperatively and one dose of Clexane postoperatively. The coroner found his medical care was reasonable and appropriate. A key clinical lesson concerns documentation: the VTE risk assessment was conducted but not recorded in the medication chart, creating confusion during the coronial review. This highlights the critical importance of contemporaneous documentation of all clinical decisions, particularly regarding VTE risk stratification, to ensure continuity of care and facilitate future clinical review. The case demonstrates that despite appropriate prophylaxis measures, postoperative VTE can occur; clinicians should maintain heightened clinical suspicion for DVT/PE in post-surgical patients presenting with new symptoms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Recent umbilical hernia repair surgery
- Obesity
- Age 74 years
- Cardiac hypertrophy
Coroner's recommendations
- Bass Coast Health remind staff members involved in the care of patients of the importance of completing thorough, legible and contemporaneous documentation.
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