Inquest into the Death of Dylan James RILEY
Deceased
Dylan James RILEY
Demographics
16y, male
Date of death
2015-08-01
Finding date
2019-09-23
Cause of death
pulmonary embolism secondary to nephrotic syndrome
AI-generated summary
Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia and hypotension during a disease relapse. Doctors appropriately diagnosed acute pulmonary oedema—a common complication of nephrotic syndrome—and transferred him to Fiona Stanley Hospital's ICU. Although PE was considered and prophylactic anticoagulation (Clexane) was given, no specific investigations for PE were performed initially. When symptoms persisted, an echocardiogram revealed massive PE with right heart failure. Thrombolysis was attempted but failed. Expert opinion confirmed that PE is extremely rare in paediatric steroid-responsive nephrotic syndrome; the medical approach focusing on the more common diagnosis of pulmonary oedema was reasonable. Earlier PE diagnosis would have offered the best chance of survival, but experts could not definitively state it would have altered the outcome. No medical errors or failures were identified; the case represents a tragic, rare, and difficult-to-predict complication.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- nephrotic syndrome relapse with fluid retention
- delayed diagnosis of pulmonary embolism
- focus on more common diagnosis of acute pulmonary oedema rather than rare complication of PE
- prophylactic anticoagulation may have been insufficient to prevent established clot
- possible disseminated intravascular coagulation triggered by inflammation
Coroner's recommendations
- Fiona Stanley Hospital implemented a separate on-call ICU echocardiography roster to enable bedside echocardiography screening for right ventricular dilation and dysfunction at any time, which may identify massive PE and trigger confirmatory testing or earlier thrombolytic therapy
- Maintain awareness among medical staff of the rare complication of pulmonary embolism in nephrotic syndrome, particularly in adolescent patients
- Continue re-evaluation of diagnosis if symptoms such as persistent tachycardia and breathlessness do not resolve as expected
- Include Dylan's case in teaching and training of junior doctors to highlight the need to exclude worst-case scenarios while avoiding over-treatment
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