Finding into death of Guy Christian Mason
Deceased
Guy Christian Mason
Demographics
48y, male
Date of death
2023-09-17
Finding date
2026-08-17
Cause of death
Pulmonary thromboembolism
AI-generated summary
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptures in a motorbike collision on 15 August and was WHO Class II obese—both major VTE risk factors. The coroner's investigation identified critical gaps in care: extended VTE prophylaxis was not prescribed upon discharge from the initial hospital admission contrary to organizational guidelines; signs of deep vein thrombosis (foot/ankle swelling and pain) at the outpatient appointment on 6 September were attributed to the initial injury and not investigated; identical symptoms presented to ED the next day were missed due to diagnostic anchoring; pre-operative assessment failed to investigate for DVT despite documented moderate VTE risk. The coroner found that extended VTE prophylaxis per guidelines would have significantly reduced his VTE risk. While acknowledging that VTE is never 100% preventable, the death was possibly preventable with appropriate diagnosis and/or prophylaxis.
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 motorbike collision (rider)
- WHO Class II obesity
- Patellar tendon repair surgery
- Failure to provide extended VTE prophylaxis after discharge
- Underappreciation of VTE risk
- Missed opportunities to diagnose deep vein thrombosis
Coroner's recommendations
- Share findings and lessons of review with relevant employees with focus on learning and improvement
- Incorporate findings into organizational improvement programs and SAPSE database
- Present VTE risk assessment as essential component at all craft group meetings for both nursing and medical staff
- Provide finding to Safer Care Victoria, Australian Orthopaedic Association, and Australian Commission on Safety and Quality in Healthcare for consideration of outpatient VTE prophylaxis management guidelines
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