Coroner's Finding: HARRAP Jean

82y · Female·bilateral pulmonary thromboembolism due to left calf deep vein thrombosis

Jean Harrap, 82, died from bilateral pulmonary embolism secondary to left calf deep vein thrombosis while detained under a Mental Health Act Inpatient Treatment Order. She presented to ED with altered mental state, self-harm, and suicidality. Investigations (bloods, CXR, CT) were normal. She was appropriately detained for psychiatric assessment. The coroner found the DVT could not have been anticipated or identified, and that death could not have been prevented. No clinical errors in diagnosis, mental health assessment, or management were identified. The case highlights the challenge of detecting occult thromboembolism in acutely unwell elderly patients presenting with psychiatric symptoms.