Coroner's Finding: SILLAND Asta

83y · Female·massive pulmonary thromboembolism due to left lower leg deep venous thrombosis

An 83-year-old woman with Alzheimer's dementia died at a residential care facility from massive pulmonary thromboembolism secondary to left lower leg deep venous thrombosis. She collapsed in a toilet cubicle and was found approximately three hours later. The coroner found the facility maintained reasonable and appropriate standards of care and that the delay in discovery did not contribute to her death. No clinical errors or preventable factors were identified. The case highlights the challenges of monitoring dementia patients in secure facilities and the unpredictable nature of thromboembolism.