Coroner's Finding: BYRNE Philip John and WEAVER Jacqueline

Philip Byrne: pulmonary thromboembolism due to right calf deep vein thrombosis; Jacqueline Weaver: pulmonary thromboembolus with contributing ischaemic heart disease

Two patients died from pulmonary thromboembolism caused by undiagnosed deep vein thrombosis (DVT). Mr Byrne presented with right calf pain in February 2012; two GPs excluded DVT on clinical examination alone without ordering ultrasound despite his history of previous DVT. Mrs Weaver presented with left calf pain, chest pain and palpitations in August 2012 after recent long-haul travel; her GP diagnosed muscle strain and stress without considering DVT or ordering imaging. Both patients died suddenly 2-3 weeks later. The coroner found both deaths preventable through timely ultrasound imaging and anticoagulation. Key lessons: DVT cannot be reliably excluded clinically; calf pain without clear trauma warrants objective testing; recent long-haul travel is a critical risk factor; Wells Score System has limitations in community practice; GPs must maintain high diagnostic rigour and communicate with allied health practitioners about DVT concerns.