Finding into death of Vicki Karon Grigg
Deceased
Vicki Karon Grigg
Demographics
67y, female
Date of death
2025-07-13
Finding date
2026-07-23
Cause of death
Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributing condition of WHO Class III obesity
AI-generated summary
Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophylaxis (40mg enoxaparin daily). The coroner identified several critical clinical failures: VTE risk was never formally assessed on admission despite this being mandatory; her high-risk profile (BMI 51.6, age >60, chronic lung disease) was not recognized or documented; standard prophylaxis dosing was not adjusted for her weight despite guidelines suggesting higher doses for obese patients; no haematology consultation occurred despite strong guideline recommendations; and VTE risk was not reassessed before ceasing anticoagulation at discharge. Clinical lessons: implement mandatory VTE risk assessment tools at admission and discharge; document all risk factors; adjust medication doses for individual patient factors; consult specialists when guidelines recommend; and always reassess prophylaxis needs before discharge, particularly for high-risk patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to conduct and document VTE risk assessment at admission
- Failure to recognize obesity (BMI 51.6), age, and chronic lung disease as VTE risk factors
- Standard-dose enoxaparin prescribed without considering patient weight or risk profile
- No consultation with haematology service despite guideline recommendations
- VTE risk not reassessed at discharge
- Anticoagulation ceased without documented clinical reasoning
- Poor documentation of clinical decision-making
- Possible independent VTE risk from corticosteroid use not considered
Coroner's recommendations
- Goulburn Valley Health should develop evidence-based tool(s) or checklist(s) for VTE risk assessment to be completed upon admission and at discharge (when indicated), and revisit the previously rejected proposition that such assessment be attached to the patient's medical records
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