Finding into death of White-Wolf Patricia Mclellan

44y · Female·Pulmonary thromboembolism complicating a fractured left ankle (not operated), sustained in a fall

A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation leading to bedbound status. No VTE risk assessment was documented at initial ED presentation or fracture clinic follow-up despite changed immobilisation level. The coroner found that while an opportunity to assess VTE risk was missed, risk assessment tools available at the time would not have predicted PE or altered management. The case highlights a gap in guidelines for VTE prophylaxis in non-hospitalised patients with lower limb immobilisation. No individual clinician failures were identified. Recommendations focus on updating state and national guidelines to address VTE risk in outpatient immobilised patients.