Channell & ivanoska decision

Female·Pulmonary thromboembolism due to deep vein thrombosis following lower leg fracture

Two women aged 48 and 59 presented to Shellharbour Hospital ED with lower leg fractures sustained in falls. Both were treated conservatively with immobilization (splint and plaster back slab) and discharged home without assessment for venous thromboembolism risk or prophylaxis, despite multiple VTE risk factors: marked obesity (BMI 43.4 and 37.4), immobility from immobilization, age, and in one case possible lupus and previous varicose veins. Both died at home within days from fatal pulmonary embolism secondary to deep vein thrombosis. Expert witnesses unanimously agreed both should have received VTE risk assessment and pharmacological prophylaxis (low-molecular-weight heparin). The treating doctors failed to consider VTE at all; subsequent statements contradicted inquest testimony. A critical system gap was identified: VTE guidelines applied only to admitted inpatients, not ED discharges, despite identical risk profiles. The coroner found the deaths represented a 'missed opportunity' where both patients were denied potential benefit of prophylaxis. Recommendations include ED guidelines for VTE assessment in leg fracture patients, routine BMI recording, and education on clinical judgment independent of protocol.