Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coronary atherosclerosis and cardiomegaly

Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo processing), was discharged, then readmitted in October 2019 with worsening respiratory symptoms including haemoptysis—a 'red flag' for PE. Despite explicit documentation of concern about PE at 9 October presentation to Hay Medical Centre, this concern was not documented in hospital records. Paul was never transferred to Griffith Base Hospital for CT pulmonary angiography (CTPA)—the only test that could have definitively diagnosed PE. The coroner found that PE should have been considered earlier, transfer should have occurred on 9, 10, 15 or 16 October, and Q fever screening should have occurred at initial presentation given occupational risk. While earlier diagnosis might not have prevented death, appropriate escalation and imaging protocols were not followed. Critical failures included diagnostic anchoring on 'most likely' (pneumonia) rather than ruling out life-threatening conditions, failure to escalate despite deteriorating oxygen saturation, and poor communication between medical centre and hospital records.