Inquest into the Death of Renee Desiree RUYZING

21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg

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.