Inquest into the Death of Squires, John Gregory
Deceased
John Gregory Squires
Demographics
47y, male
Date of death
2009-09-02
Finding date
2013-05-01
Cause of death
Pulmonary thromboembolism in association with deep vein thrombosis
AI-generated summary
A 47-year-old man from Carnarvon underwent elective laparoscopic cholecystectomy at Geraldton Regional Hospital on 31 August 2009 after a 5-hour coach journey that morning. The VTE Risk Assessment Form correctly classified him as high-risk and recommended thromboprophylaxis, but surgical staff considered him low-risk based on the minimal invasiveness of laparoscopy. He developed progressive oxygen desaturations (80-90%) on 1 September requiring supplemental oxygen, which nursing and medical staff did not escalate appropriately. On 2 September he presented with chest pain, dyspnoea, and sweating. Despite rapid recognition by medical staff and appropriate investigations, he suffered cardiac arrest from massive pulmonary embolism with DVT before anticoagulation could be beneficial. Key preventable factors included: lack of pre-operative anticoagulant prophylaxis despite high-risk classification; failure to adequately escalate oxygen desaturations on 1 September; and lack of awareness that same-day long-distance travel immediately before major surgery represents a significant VTE risk factor. Implementation of modern oxygen-saturation response protocols and explicit consideration of pre-operative travel duration in VTE risk assessment are recommended.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to prescribe post-operative thromboprophylaxis despite high-risk VTE assessment
- lack of awareness of pre-operative long-distance travel as VTE risk factor
- failure to escalate progressive oxygen desaturations on post-operative day 1
- inadequate clinical decision-making in weighing VTE risk factors
- split documentation system (observations chart and integrated progress notes) obscuring clinical picture
- lack of mandatory clinical response protocols for abnormal vital signs
- delayed recognition of pulmonary embolism symptoms
Coroner's recommendations
- WACHS to facilitate a review of the VTE Risk Assessment Form to consider inclusion of the type and duration of travel of pre-operative patients
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