Inquest into the Death of Keogh

Contributing factors

• Nephrotic syndrome with decreased anti-thrombin III levels
• Recent major abdominal surgery (distal pancreatectomy and splenectomy)
• Post-operative complications including pancreatic leak and sepsis
• Elevated platelet count post-splenectomy
• Immobility during prolonged hospitalisation
• Complex anticoagulation management with multiple procedure-related interruptions
• Right basilic vein thrombosis (4 October 2008)
• Failure to obtain diagnostic records from initial DVT/PE investigation

Coroner's recommendations

1. Sir Charles Gairdner Hospital should create a separate tab in patient medical files entitled 'Orders' which records instructions and orders by consultant surgical teams and treating medical practitioners, including all decisions to change patient medications and decisions made not to institute particular medications.
2. Sir Charles Gairdner Hospital should consider developing guidelines or protocols for obtaining advice and guidance from consultant haematologists in relation to the management of patients at higher levels of risk of developing a deep vein thrombosis or a pulmonary embolism.
3. Discharge summaries prepared by SCGH (including those prepared for SCGRU) should be amended to include a section for the surgical consultant discharging the patient to write current orders and directions about the patient, giving short reasons, and contact details for consultation.
4. Sir Charles Gairdner Hospital should consider developing a Thrombosis Management Service to provide specialist advice in relation to patients with increased risk of deep vein thrombosis and pulmonary embolism.