Deceased
Renee Desiree RUYZING
Demographics
21y, female
Coroner
Deputy State Coroner King
Date of death
2015-06-14
Finding date
2020-10-19
Cause of death
pulmonary embolism in association with deep vein thrombosis of the left leg
AI-generated summary
A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (immobilisation, oral contraceptive use, obesity, family history of clotting). FSH had two conflicting guidelines: one recommending enoxaparin throughout immobilisation, the other recommending aspirin. The patient was not prescribed either agent after discharge. Expert evidence revealed lack of consensus on VTE prophylaxis in lower limb fractures, but most experts agreed the patient should have been risk-stratified and offered prophylaxis. Key failures included: non-completion of risk assessment documentation, failure to obtain family history despite father's stated concerns, and non-adherence to FSH's own guideline. Systemic issues included unclear guidelines, poor risk stratification tools, and inadequate patient education.
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
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