Deceased
Robert John Robinson
Demographics
74y, male
Coroner
Coroner Audrey Jamieson
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…
A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…
70y · Male·haemoperitoneum, ruptured spleen, colonoscopy
Alan Stewart, age 70, died from haemoperitoneum and ruptured spleen approximately 36 hours after an elective colonoscopy at Royal Melbourne Hospital. A splenic injury occurred during the procedure, likely due to mechanic…
73y · Male·Haemorrhagic stroke in the setting of recent inguinal hernia surgery and change …
Paul Turner, 73-year-old with atrial fibrillation and aortic valve replacement, underwent elective bilateral inguinal hernia repair in August 2018. His cardiologist advised ceasing rivaroxaban 3-4 days preoperatively; ho…
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