Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary embolism; bedside ultrasound showed right ventricular strain. Despite presumptive diagnosis of PE being made, no anticoagulation or thrombolytic therapy was initiated. Instead, staff waited for CT pulmonary angiogram, which was delayed due to absent pathology results, unfamiliar ordering systems, and lack of radiographer on-site. Patient remained ramped (in ambulance) for 8 hours due to full ED and no available beds. She arrested and died before imaging could be performed. Coroner found management was substandard; immediate anticoagulation/thrombolysis was essential and should have been given based on clinical presentation and ECG findings, regardless of definitive imaging. Multiple system failures contributed: inadequate ED orientation for new medical staff, lack of clear protocols for urgent out-of-hours pathology and radiology requests, nursing staff deficiency, and resource constraints from ramping.