Coroner's Finding: Harper, Marlene Jean

72y · Female·multiple bilateral pulmonary infarcts caused by multiple pulmonary thromboemboli due to deep vein thrombosis

Mrs Harper, aged 72, with chronic lymphocytic leukaemia presented with superficial thrombophlebitis of her right leg in March 2015. She was managed conservatively with bandaging and aspirin by general practitioners. On 18 June 2015, despite ongoing leg tenderness, duplex ultrasound investigation was not ordered to exclude deep vein thrombosis, despite multiple significant risk factors: CLL (which increases DVT risk 3-10 fold), superficial thrombophlebitis location at the saphenopopliteal junction (associated with concurrent DVT in 6-53% of cases), and her history of prior superficial venous thrombosis. She deteriorated acutely on 20 June with respiratory failure and died at Royal Hobart Hospital. Post-mortem examination confirmed multiple bilateral pulmonary emboli arising from an undiagnosed DVT. The coroner concluded her death may have been prevented by timely ultrasound imaging and anticoagulation. The case underscores the critical importance of investigating for DVT in patients presenting with superficial thrombophlebitis in high-risk anatomical locations, particularly those with inherent thrombophilic conditions.