Coroner's Finding: Brook, Jason Mark

45y · Male·massive pulmonary embolism due to deep vein thrombosis of the left leg

A 45-year-old man died of massive pulmonary embolism secondary to deep vein thrombosis, 15 days after a motorcycle injury in Thailand requiring surgical wound management and foot fracture immobilization. He was discharged with the fracture in a plaster cast but did not receive prophylactic anticoagulation therapy. The coroner found he was at high risk for DVT (lower limb fracture, infection, prolonged immobilization) and should have received anticoagulation throughout his immobilized period, both in hospital and post-discharge. A medical consultant concluded that anticoagulation would have significantly reduced DVT risk and likely prevented his death. Multiple system failures were identified: the surgeon's ambiguous post-operative instruction ('clexane tonight'), junior doctor misinterpretation (single dose instead of ongoing), no anticoagulation prescribed at discharge, and senior clinicians failing to notice the omission on ward rounds. The hospital acknowledged the failure, undertook root cause analysis, and committed to VTE protocol education and audit.