Coroner's Finding: Woolley, Paul James

50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngeal surgery for obstructive sleep apnoea

A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failure to ensure continued CPAP use despite surgeon and anaesthetist expectations, and absence of continuous oxygen saturation monitoring. The patient suffered undetected hypoxia overnight, leading to respiratory arrest and subsequent thromboembolism. Autopsy revealed heparin-induced thrombocytopenia as a contributing factor. Had CPAP been used or continuous pulse oximetry implemented, the patient would likely have survived. The hospital lacked a specific UPPP clinical pathway and staff were misinformed about CPAP safety post-operatively. The case highlights critical communication failures between surgical teams and nursing staff, inadequate post-operative protocols for high-risk airway surgery patients, and the importance of explicit written orders.