Finding into death of Carmel Killackey

77y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis of the left leg

A 77-year-old woman with Factor V Leiden thrombophilia and history of PE presented to a rural urgent care centre on 19 April 2017 with shortness of breath and chest pain. She was examined by Dr H. who considered but dismissed PE as a diagnosis, attributing symptoms to possible gastrointestinal cause after a diagnostic trial of antacid. She was discharged without ECG, without verification of anticoagulation status (INR test), and without repeat vital signs. She collapsed at home the next day with fatal pulmonary embolism and DVT. Key clinical lessons: PE must be actively considered in patients with thrombophilia presenting with dyspnoea and chest pain; anticoagulation status should be verified by INR testing rather than accepting patient report; ECG is mandatory in chest pain presentations; risk stratification tools should guide investigation; repeat observations before discharge are essential when diagnosis uncertain.