Finding into death of Shane Peter Kerstjens

42y · Male·Pulmonary thromboembolism and deep calf vein thrombosis

Shane Kerstjens, a 42-year-old man with cerebellar dystrophy and intellectual disability, died from pulmonary thromboembolism and deep vein thrombosis. He sustained a tibia and fibula fracture on 6 September 2007, requiring surgical fixation. Although prescribed clexane (low-molecular-weight heparin) for thromboprophylaxis until 4 December 2007, he was transferred to rehabilitation at Bundoora Extended Care Centre on 4 October 2007. He remained largely immobilised during his recovery. On 27 December 2007, he was found unresponsive and could not be revived. The clinical lesson is that patients with significant immobility from lower limb fractures require vigilant thromboprophylaxis monitoring and assessment. Early mobilisation, continued pharmacological prophylaxis beyond discharge, and clinical vigilance for signs of VTE (leg swelling, chest pain, dyspnoea) could potentially have prevented this fatal outcome. Staff at the facility should have been alert to VTE risk given his immobility.