Bradshaw, Scott Anthony - Non-inquest findings

38y · Male·Pulmonary thromboembolism due to bilateral deep calf vein thrombi

A 38-year-old man with schizo-affective disorder, bipolar disorder, and asthma presented to the emergency department with presumed pneumonia based on fever, pleuritic chest pain, and respiratory symptoms. His general practitioner appropriately referred him urgently. The ED team treated him for pneumonia with oxygen and antibiotics. He rapidly deteriorated and died in cardiac arrest. Autopsy revealed pulmonary thromboembolism from bilateral deep vein thrombi as the cause of death, with dilated cardiomyopathy as a contributor. Experts differed on whether pulmonary embolism should have been in the differential diagnosis and whether earlier diagnosis could have prevented death. The clinical diagnosis of pneumonia was reasonable given available clinical data. Had PE been suspected, anticoagulation (not thrombolysis in non-hypotensive patients) might have been considered, but expert opinion diverged on whether this would have changed the outcome. The hospital implemented recommendations including PE education, diagnostic algorithms, and improved airway equipment.