Finding into death of Anna Agnieszka Bowditch

34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis with embolisation

Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobility from leg casting, recent long-haul flight, oral contraceptive use, and borderline obesity. The coroner found that orthopaedic surgeon Mr Widjaja's pre-operative examination of her leg was inadequate—he examined through the bandage and back-slab rather than removing them for full visualisation and palpation, a five-minute procedure. The expert panel unanimously agreed this examination was insufficient to detect possible DVT and inconsistent with good practice. Although no documented signs or symptoms of DVT were recorded pre-operatively, and risk factors alone do not mandate investigation, a fuller examination might have identified concerning signs. An undiagnosed patent foramen ovale allowed paradoxical embolism to the brain. While the death was causally related to surgery, it was deemed not preventable on balance of probabilities, as DVT could have occurred regardless with similar fatal consequences.