Finding into death of Magdalena Dorter

58y · Female·Haemorrhagic shock complicating pulmonary thromboembolism in the setting of deep vein thromboses following a foot fracture sustained in a fall

A 58-year-old woman with obesity (BMI 38) sustained a metatarsal fracture and was treated with a below-knee plaster cast by her GP. Despite appropriate initial assessment and consultation with a haematologist regarding VTE prophylaxis, she developed extensive deep vein thrombosis and pulmonary embolism with a saddle embolus, leading to haemorrhagic shock and death. The coroner found the care provided was reasonable and appropriate, with no evidence the death could have been prevented. However, the finding highlights a critical gap: Australia lacks current national VTE prophylaxis guidelines for outpatient immobilised patients, particularly obese individuals. The coroner expressed concern about this regulatory vacuum and recommended development of new national VTE guidelines to prevent similar deaths.