Mr P - Non-inquest findings

47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbid obesity

A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsville Hospital's ICU, clinicians anchored on pneumonia as the diagnosis despite the requesting physician's PE concerns. Venous doppler ultrasound was deferred based on chronicity of leg swelling; the requested CTPA was not ordered. The patient received only prophylactic anticoagulation (heparin 5000 units BD), insufficient for treating established PE. After discharge to Ayr Hospital with apparent improvement, he suffered fatal PE on day 5. Autopsy revealed extensive pulmonary emboli and DVT in pelvic and lower limb veins. The coroner concluded that failure to apply clinical risk-stratification tools (Wells Score), perform recommended imaging, and escalate to therapeutic anticoagulation represented missed opportunities. Best practice would have required low threshold for investigating PE in high-risk patients despite alternative diagnosis.