Coroner's Finding: Paul Justyn Brauer

64y · Male·Large pulmonary embolus (origin undetermined)

Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner identified significant system failures: warfarin was recommended by multiple doctors but never seriously considered despite AF and previous stroke; discharge planning on 12 September failed to follow policy with no written care plan or agency coordination; post-discharge monitoring was inadequate, allowing marked deterioration by 26 September; case management was not implemented; escalation occurred too late. Expert evidence was divided on whether anticoagulation would have prevented the PE. The coroner could not establish causation between the documented failures and death because the PE origin remains undetermined. Deep vein thrombosis from immobility was likely. Recommendations include appointing coordinating clinicians for complex patient management and discharge planning at both hospitals.